A Paradigm Shift in Medical Education, Transitioning to Integrated Curriculum: A Faculty Point of View

Jimmy Michael Younger, Vivek Joshi^*, Sanjib Das, Raghvendra Vikram Tey, Pallavi Haldankar, Manjunath Goud and Kartick Pramanik

^*Correspondence: Dr. Vivek Joshi, Department of Biochemistry and Molecular Biology, Drexel University, Philadelphia, Pennsylvania, USA, Email:

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Introduction

Education has been a cornerstone of the civilized world since the early seventeenth century. Over the years it has undergone tremendous change. The initial change was to extend the education from a select few to a much larger population that deserves equal opportunity but also the way in which it was delivered. One such modification includes the integration of various subjects at a point. The term integration has been around for more than half a century. According to several authors, like from the time of Flexner’s report of 1910 on medical education, which transformed how the education was delivered before this report [1]. This report led to enormous modifications in medical school curricula and established the biomedical model as the gold standard, which is still being followed by several universities in the United States and other countries but also resulted in the elimination of the proprietary schools [2]. This report became the prototype structure to be followed by all the universities in the United States and Canada, as most schools adopted the structure with two years of basic science followed by two years of clinical science. Though this system was accepted by many, it still had its deficiencies most notably the passive methods of teaching and delivery of knowledge and concepts in a fragmented and isolated system during the preclinical years. It also focused more on hospital treatment rather than on a healthcare system that was the need of modern society [3,4].

During the late sixties and early part of the seventies, many universities tried several methods to improve the failing medical system, the most accepted modifications in medical education included the advent of a problembased approach and integrated medical curriculum which were more interactive and involved enhanced communication between the peers. The other approach being envisioned at the same time that assisted the problem-based education was the integrated medical curriculum [5,6]. The Shoemaker’s definition of integrated curriculum is “an organized education system which cuts across the subject matter, brings together different aspects of the curriculum into the meaningful association to focus on broad areas of study”. These approaches led to the restructuring of preclinical education, primarily moving from discipline-based to integrated, some concepts delivered and learned by problem-solving and a major change in clinical education being the introduction of Objective Structured Clinical Examination (OSCE) using simulated patients, benefits of formative and summative assessments for medical knowledge. The integration can be horizontal integration, vertical integration, and spiral integration, all these models differ in two basic relevant components of the medical curriculum as the reference point, time, and the several basic and clinical science subjects [7]. The main idea which attracted this model was it put students at the centre of the educational process. Following these transformations, the universities have tried blended or thematic learning to accommodate learners with different learning styles and adaptability. Many authors have reported the advantages of the PBL system while comparing the system developed by Flexner et al, though emphasizing that no system is perfect [8,9]. As viewed by many, an integrated medical curriculum with a problembased approach is the best method to drive medical education forward in the twenty-first century by utilizing either blended or thematic learning approaches, though there are various flaws and difficulties which are overlooked and neglected. What we should realize is that large parts of the world is still following discipline-based medical education and are successful in all the attributes which are being emphasized in the integrated model.

The major difference mentioned by various authors between the two methods used in medical education was that in Flexner’s model, the students in preclinical years did not experience nor observe the relevance of obtained medical knowledge to their future clinical practice, compare this to the integrated medical curriculum which exposes the students to clinical scenarios very early in their formative years and teach students to think like physicians from the very first day. Thus, it is perceived that the students from universities that adopt integrated medical curricula were better prepared to serve the community and understand the needs of society to which they will be catering to [10-12]. Also, the integrated system helped further pave the way to develop the competencies which are being utilized by various universities to assess the quality of student physicians. Though the advantages of an integrated system are many but as mentioned before the deficiencies have been overlooked and maybe the discipline-based traditional education has been unfairly judged as being completely ineffective. As an educator, we understand that no system of learning fits everyone and not one system is perfect, keeping this in mind it is necessary to keep an open perspective and maybe use a model which has the positive attributes from both systems rather than flipping the educational system at the university by 1800 and using the opposite system.

The main objectives of this realist review article are to focus on the issues which have largely been overlooked, predominantly involving the faculty. Have the rapid modifications and changes in the curriculum design been unfair on the faculty, have they been given enough time, resources, and guidance to adapt and accept the everevolving education system? Here we just try to make the argument on behalf of the faculty, are ready to step into unchartered territory, and do they have enough resources and guidance required to navigate through the testing times.

Materials and Methods

This study was conducted using the systematic review of articles published on the topics of traditional curriculum and integrated or problem based or competency based curriculum and the student or faculty perception towards these curriculum styles. The article utilized in this review were collected from various electronic bibliographic databases like PubMed, Google scholar, e Journal’s, SCOPUS, Medline, and personal experience and observation of the authors involved in this article (Table 1). The articles published after 2011 were considered for the review, only the original research was included in this narrative review. The review articles were eliminated. We utilized a narrative approach while discussing the results from 23 different articles out of 229 articles explored.

Table 1: Database searched for the articles.

Results

Evaluation of different curriculum styles

Various resources and methods have been utilized to assess the quality and satisfaction by comparing the traditional curriculum with the integrated curriculum (Table 2). The integrated curriculum is a way of modernizing the existing medical education and is used to attract Gen Z students, to occupy the leadership position in the educational reform process while competing with other reputable organizations. But does it solve the issues we face in the 21^st century? Many scholars agree that the quality of higher education is declining in the modern world, should we then continue to follow suit with the reputable university and change or take a moment to pause and indulge in self-introspection, analysis and review the curriculum in hand and take small steps required in curricular revision, rather than paradigm shift. Undoubtedly the integrated curriculum has its advantages mainly it encourages and emphasizes the acquisition of knowledge and self-learning of skills by the students, learning and understanding the whole concept, in comparison to segmented learning of knowledge and skills by the students and then the difficulty in combining them later as seen in traditional learning. Based on the data analyzed there was no significant change in the level of education delivered when the universities changed their curriculum from traditional to integrated curriculum. This integrated curriculum was delivered in different interactive formats, like lecture-based integrated curriculum, PBLintegrated curriculum, blended-integrated curriculum, CBL-curriculum. The outcome of the high-stakes examinations was not conclusive when migrating from traditional to integrated curriculum. According to a study conducted by Gustin, et al. the success rate on high stakes examinations varied from 17% to 40% for students who were taught by the traditional discipline based curriculum to as high as 50% to 98% success by an integrated approach. In comparison the other studies like Vashe, et al. did not find any significant difference in the two curricula, they observed that students following traditional discipline based curriculum had an average of 83% and the students on the integrated approach had an average of 86%. Similar trends can be observed in studies from other scholars as well [13,14].

Table 2: Evaluation of curriculum style.

The other advantage noted by the authors is the scope for interactions or developing communication skills in the medical student. A study conducted by the University of Manchester, UK by Watmough, et al. about the improvement in communication skills in the medical school graduate who has experienced PBL-based curriculum compared to those who have had a traditional disciple-based curriculum, they divided the communication skills into three categories, more than quite competent, generally quite competent, or less than quite competent. The results in the three categories were in favour of the PBL cohort (60%, 42% and 5%) compared to the traditional cohort (41%, 38% and 12%). These findings encouraged the changing trends in Europe and North America, where the stakeholders prefer reducing the lecture hours and promoting studentcantered learning activities by preferring the teaching and learning “by ear,” which is to enhance the knowledge through verbal discussions [15].

Students preference to curriculum style and learning environment

The major attraction towards the integrated curriculum was based on the perception of the learning environment for the learner group (Table 3). According to Miles, et al. they observed that the most crucial factor which influences student satisfaction with the curriculum and their academic success is the educational environment they are enrolled in. The Dundee Ready Educational Environment Measure (DREEM) is used to evaluate the student learning environment as it has been validated and used widely. They observed that following curriculum revision to integrated curriculum, the result analysis provided a score of 152.5 (± 15.4)/200, which indicates an excellent learning environment. Comparable results were also observed by Gustin, et al. the score observed by them ranged from 136.3 to 139.5 (± 17.3) for the integrated curriculum. But significantly they also observed a DREEM score of 122.0 to 125.2 (± 18.2) with traditional curriculum, depicting that the two systems were comparable on the student learning environment. The learning environment along with the perception of student learning can then provide insight into the types of learning approaches, which are deep learning or surface learning. Authors have defined the “deep learning approach” as the one in which the students understand what they are learning, can relate to new information based on prior knowledge, and can critically evaluate the medical knowledge gained and then draw the conclusion. The “surface learners” on the other hand depend on memorizing and reproducing the content to pass an examination or retain the information for a short while [16,17]. Several studies report the qualitative data regarding the student’s perception of the learning environment and curriculum style. The results are inconclusive as some scholars such as Dochy, et al. observed that integrated curriculum offered an enjoyable learning experience, with improved perception about the quality of life, thereby increasing the possibility to achieve adequate learning development [18]. In comparison Atta, et al. reported that several students found the integrated curriculum to be stressful; this design has a greater number of credit hours applied for a whole program, a high number of assessments for each course. The other main observation reported by them was the lack of gap between the courses, long learning hours, overlapping between subjects, and lack of clarity between the courses. The quantitative analysis of learning environment and student perception of medical knowledge was done by Gustin, et al. who observed that integration of curriculum using PBL improved the students’ academic and learning perception but also had a positive impact on social self-perception. The student perception for PBL-integrated learning (136.3 ± 17.3) was better than the lecture-based curriculum (105.4 ± 21.3). The deep approach for students in PBL-IL (33.7 ± 5.7) was also higher than lecture-based learning (29.5 ± 5.9).

Table 3: Students preference to curriculum style.

Faculty capacity building

Various scholars like Bland, et al. have noted in their work that reforms will always entail resistance from those who experience the change; it is not surprising to note that no faculty is the exception to this principle. As pointed out in various articles, the integrated curriculum may be the chosen system of curriculum delivery by two stakeholders in learning, the administration, and students. But there are very few articles that are published that depict the choice and perspective of other stakeholders, who are conveniently forgotten, the faculty [19,20]. Very few universities involve faculty in their curricular revisions or reform process, but rather the process and decision are discussed by a select few (Table 4). Based on the data analyzed, the major resistance to curricular reform by faculty was due to lack of attention and resources provided towards the capacity building of faculty, which is essential towards implementing the new system, lack of understanding of the process and mechanism to get the system started and the duration afforded to faculty for this change or reform. Also, the major pitfall towards the system is lack of infrastructure and resources for conducting this system at the time of restructuring the curriculum, rather the faculty body deliberated that the planning and preparing for resources and learning needs should take precedence over implementing the new system for sake of modernization of learning. The other disadvantage observed by various authors like Amini, et al. was lack of faculty development towards the knowledge update and teaching and learning styles which is required to be effective in the integrated model in comparison to the traditional model, it was also observed that the reform was done in haste with complete lack of time required to make the necessary change from traditional discipline-based to integrated curriculum. It was also noted that the active learning modules involved in integrated curriculum require far greater man-hours and resources, and the onus and responsibilities of which are faculty responsibilities, which to an extent in most universities was blindsided while planning and implementing the new curriculum. This puts tremendous pressure on faculty and students and may be a factor causing an increase in burnout. It should be noted that various authors point out a glaring lack of faculty body participation while planning and reforming the curriculum which is a trend in small to medium-sized universities, the larger universities fair better in the duration to implement and faculty participation category [21-23].

Table 4: Faculty capacity building and barriers in implementation.

Barriers in implementing the curricular change

In general, the faculty, students, or administrators are not against reforms or changes recommended towards the curriculum, but every medical university which has utilized a traditional discipline based curriculum will face some resistance when migrating towards the integrated organ system-based curriculum. This resistant behaviour is not due to a lack of motivation or regressive mindset but is due to a multitude of factors that needs to be addressed or discussed and worked on. Based on the articles we have analyzed, a general trend noticed by the students when the curriculum was changed from discipline-based to integrated curriculum was the lack of use of deep approaches, the students were more stressed in the integrated curriculum due to the increased number of courses and the credit hours for those courses and the simultaneous arrangement of the courses and the high number of assessments associated with the program [23,24]. The students also noticed significant loss of gaps between courses and loss of teaching tools and subject concepts. Some observations made by faculty were that decreasing lectures to incorporate social discussion for learning outcomes would set aside many important topics that students will not learn, and which may affect the quality of medical education. The other major barrier towards implementing the integrated curriculum was the complexity in the integration of assessment, as medical education utilizes a wide range of assessment methods, the faculty, and program directors need to be sure which assessment tool needs to be used to capture the intended assessment outcome. The other concern which was often reported was the uncertainty about the required learning objectives which mostly stem from a largely open curriculum. Also frequently noted by the faculty was the relative lack of flexibility in the course design and implementation, unstructured work hours, lack of standardization of teaching input and quality, and relative lack of freedom and flexibility in the course content and delivery [24-26].

Discussion

This review article provides a realist review on the difficulty in accepting the newer forms of curriculum delivery by both the students and faculty and the possible disadvantages of continuing the old traditional approach in delivering the medical education. We have observed the advantages and disadvantages in both the traditional discipline based curriculum and the newer integrated or problem based, or organ system based curriculum, which range from resistance from the participating faculty to delivery of the content while terminating in dissatisfaction about the assessment outcomes from students and administrators.

Principal findings

The most important observation in favour of novel integrated or problem based format made by most studies was the student performance on high stakes examination, this is derived from the fact that most of the board examinations utilize integrated and higher order questions for external assessment which has attracted the administrators and majority of gen Z students to accept this method. Though the result after analyzing several studies is variable, the student performance on high stakes examination is comparable. This is just one aspect of the observation, other points in favour of the new format are the scope towards developing the selflearning skills, ability to acquire knowledge, stimulate the lifelong learning and understanding the concept at a time rather than fragmented.

Our review also observed that the most crucial factor attracting the students towards an integrated or problem-based curriculum was the learning environment as mentioned by Miles et al. compared to traditional discipline-based curriculum the newer formats provided better satisfaction to learning needs and more enjoyable experience. But a major section felt the newer forms to be more stressful and lack of clarity or gap between courses [27].

The other stake holders in the education, like the faculty involved have a more pragmatic view. The faculty view several barriers when transitioning from traditional discipline based to integrated or organ system-based curriculum, which are easily neglected or overlooked. Some of the barriers observed were the extent of faculty involvement during the development and planning of the curriculum, lack of resources or capacity building provided to faculty and staff during the transition, myopic view towards the need for infrastructure or resources required for transition or starting the newer forms of curriculum delivery and the additional man hours required to plan the course content or assessment methods or for integration of the core concepts with other subjects. Numerous studies have observed a relative lack of faculty participation during the planning, designing, marketing, logistical analysis phase of curriculum management in several universities, but some universities have these changes being driven and managed by the faculty involvement to a larger extent [28,29].

The other relevant observation made after analyzing several studies was the reluctance towards certain aspects of newer format from students and faculty alike. The major problem observed by students was the lack of deep approaches while learning a concept or course content on one hand and excessive burnout due to heavy course credit load and substantially high number of assessments. On similar grounds the faculty also felt that migrating towards integrated curriculum would significantly decrease the student contact hours with faculty to integrate more social and peer discussion which may have detrimental effect on understanding of some core concepts, also the faculty were mindful about the possible knowledge gap and lack of flexibility and creativity in course content delivery and design. It should be noted that based on above observation, no one model fits all, both the curriculum styles have their advantages and disadvantages. One curriculum may enhance the install the self-directed learning skills and enhance communication skills and the other curriculum has an edge in ability to drill in core concepts and better understanding of subject matter [30,31].

Critical appraisal

All the articles analyzed in this study mentioned the aim and objective for the study they conducted, they reported a justification for the qualitative method used in the study and the design of the research. The analysis revealed that few studies lacked the description of relationship between researcher and interviewer. This could have generated a bias as the interviewee’s perception may be influenced by the researcher if they are in direct contact with them due to their role as program director or teaching faculty. As some of the articles included were survey-based time sensitive research, the participation by students or faculty may be limited to those who were highly motivated or those who had a positive attitude towards the methods being used in the research or curriculum. This article lacks the data interpretation and analysis as it is a realist review but not the systematic review based on PRISMA (Preferred Reporting Items for Systematic Reviews and Meta Analyses) protocol which can be reproduced.

Conclusion

In this study we reviewed 23 studies published on perceptions of students and faculty towards the traditional curriculum and integrated curriculum which is delivered by different interactive tools like thematic learning or blended learning and using any of the formats like PBL, TBL, competency-based, organ system-based curriculum, utilizing different models of integration, horizontal, vertical and spiral integration of curriculum on students’ performance on assessments and modifications in grading after migration to newer curriculum. Firstly, the curriculum migration from traditional discipline based to integrated or newer formats is challenging and has several implications but proper mitigation, implementation and planning towards these changes can help the academic community to succeed and accept the newer curriculum. As observed by several faculties, there should be constructive discussion and encouragement and avenues for faculty participation during the planning, designing and implementation of the curriculum. Also, the deciding stakeholders should view the logistical support and availability of resources and upgrading of infrastructure as important as the implementation of the newer curriculum format or marketing of that. Second, the curriculum integration as a component of curriculum management or revision should incorporate an in-depth analysis of the setting in which it will be implemented, the requirements of students and faculty, training of faculty and staff who will be participating in the reform and open communication channel between the administration and faculty who will be at the forefront of such curriculum revision. Finally, those participating in curriculum reforms should try to balance the standardization, freedom to faculty and flexibility in learning content within the scope of curriculum with clear learning objectives. The assessment tools which will be utilized must adequately and effectively measure the students’ learning outcomes and the competencies which they are required to attain during the medical education. We recommend that the curriculum revisions, if necessary, should be done with involvement of all three stakeholders following in-dept analysis of present curriculum, its efficiencies and deficiencies and the availability of infrastructure and resources to handle and successfully migrate to newer formats. Both formats have the advantages and disadvantages, and no one model fits all.

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