Introduction:
The pre-clinical subjects like Anatomy, Physiology & Biochemistry are taught to MBBS students in their first year separately without much correlation to each other. Students may lose interest in the subject as it involves didactic lectures and evaluation based on pure recall rather than comprehension and analysis. It is essential to understand the importance of these subjects in their future curriculum and practice. The integration between the preclinical subjects is also essential to correlate the facts. Therefore, to bridge this gap between the subjects and to acquaint the students with clinical scenarios, integrated teaching is in practice.
Integrated teaching (IT) aims to cater to the students’ needs and make the subjects clear and understandable. IT is involved in connecting skills and knowledge from multiple sources and experiences and applying skills in various settings. It therefore helps in bridging connections between academic knowledge and practicals.(1)
Medical education mainly aims at producing medical professionals with good clinical competencies and community orientation with proficient communication skills. This becomes very important in the treatment of daunting health problems.(2) Tremendous responsibility is vested on the institutions providing medical education to bring about required innovations in the existing system.(3)
Majority of medical colleges in India follow the traditional curricula in teaching. This is disciplined based, teacher centered, and examination oriented. Such modules are under criticism for placing too much emphasis on memorization of facts and figures and for overloading the students with excessive details.(4) As a result, students are unable to correlate the basis of clinical problems or cases and thus could face problems during the diagnosis and treatment of a patient.(5) Teachers should assume a new role of facilitating the process of active learning rather than overloading students with excessive details through a series of elaborate lecture and voluminous book. Thus a student centered approach helps to make learning a pleasure and subsequent use of knowledge in an effective manner in clinical practice.(6)
Methodology
Integrated teaching program in our institution
In our curriculum, IT programme has been implemented and effectively practised from the past four years. It involves video demonstrations of dissected specimens, guest lectures by the clinical faculty and case presentations by the students. This is practiced in addition to conventional teaching methods.
Description of IT methodologies practiced:
Case presentations:
A group of 25 students were given a case on a particular organ system which contained questions related to anatomy, physiology and biochemical aspects. The students were given a month time for preparation and it was presented by the members of the group. A panel of faculty were assigned to judge the same.
Lectures by clinicians:
Lecture sessions by clinicians was organized by Department of Anatomy once a month. The topics were chosen in such a way that they were in accordance with the preclinical topic which was taught in a particular session.
Video demonstrations:
Demonstration of dissected specimens by the faculty at the end of academic year was introduced as a novel method for revision of the subject. The presentations were recorded and were uploaded in the computers of student learning center such that the students could access the same whenever required.
The present study is therefore an attempt to document the effectiveness of IT.
Study Design
The present cross sectional study was carried out involving 185 second year MBBS students (93 males and 92 females) who underwent Integrated Teaching (IT) in their first year. The study was conducted in Kasturba Medical College, Manipal University, Manipal and was approved by the Institutional Ethics Committee, Kasturba Hospital, Manipal. The age group of the students ranged between 18 to 20 years. All the students were given an option to participate or to decline the participation in the study. An informed consent was taken from the students who agreed to participate. A questionnaire was therefore constructed as shown in table 1, to acquire the students’ feedback regarding the benefits of integrated teaching and its impact on their learning abilities and was distributed to them in the beginning of the academic year 2014-15. The students were encouraged to give their effective feedback. The responses ranged from strongly disagree to strongly agree with a Likert scale of 1-5. The results were expressed in percentages and were tabulated.
Additionally the performance of the students was also assessed by recording their year-wise results in the university examinations. This was further compared with the results of the students who were not exposed to IT in the past years and the findings were tabulated. The results were expressed in the form of bar graphs and pie chart.
Results
IT has received tremendous positive response from the students. This also showed a positive impact on the examination results which had a progressive increase in the past three years. The students who had passed out from the first year, when exposed to clinical scenarios, affirmed that integrated teaching programme was very helpful in confidently solving clinical cases and effectively correlating clinical with preclinical subjects thus arriving at an accurate diagnosis. This opinion was seconded even by the clinical faculty.
The students’ responses to the questionnaire on IT revealed positive findings. 92.4% students agreed that IT gives confidence in approaching clinical cases and evokes interest in studying pre-clinical subjects (Graph 1). 85.8% of students agreed that IT helps to bridge the gap between academic knowledge and its application in daily practice (Graph 2). 73.4% stated that IT is better than didactic lectures (Graph 3). 75% of the students agreed that IT should be conducted twice a month or more (Graph 4).
But when asked, if IT would help them in preparing for their examinations, 55.1% students disagreed the same (Graph 5).
Overall, 90.8% agreed that implementation of IT in pre-clinical departments is beneficial and must be compulsorily incorporated in a regular teaching curriculum (Graph 6).
Table 1: A model questionnaire denoting effectiveness of integrated teaching (IT) assessed. |
| S. No. |
Aspects assessed |
1 |
IT gives confidence in approaching clinical cases and evokes interest in studying pre-clinical subjects |
2 |
IT helps to bridge the gap between academic knowledge and its application in daily practice |
3 |
IT is better than didactic lectures |
4 |
IT should be conducted twice a month or more |
5 |
IT would help them in preparing for their examinations |
6 |
IT in pre-clinical departments is beneficial and must be compulsorily incorporated in a regular teaching curriculum |
7 |
View of better teaching technique
- Case presentation with discussion in small groups
- Seminars and brain storming session
- Video demonstration of clinical scenario followed by discussion
- Lecture by clinical faculty followed by discussion
|
 |
 |
Graph 1: Integrated teaching (IT) gives confidence in approaching clinical cases & evoked interest in studying preclinical subjects.
|
Graph 2: Integrated teaching (IT) helps to bridge the connection between academic knowledge and practical. |
 |
 |
Graph 3: Integrated teaching (IT) is better than didactic lectures. |
Graph 4: Integrated teaching (IT) should be conducted twice a month or more. |
 |
 |
Graph 5: Integrated teaching (IT) helps in preparing for exams. |
Graph 6: Implementation of Integrated teaching (IT) in preclinical departments is beneficial and must be compulsorily incorporated in a regular teaching curriculum. |
When the students were asked to give their preferences on IT techniques, majority of them found video demonstrations beneficial in learning and revising while the case presentations helped them to develop the skills in public speaking. Students also affirmed that case presentations helped them a lot in detailed understanding of the subject in concern and also helped in building the quality of team work. Lectures by clinicians were interesting and encouraged them to study the pre-clinical subjects better.
Further the performance of the students was also assessed by recording their year-wise results in the university examinations. The results showed progressive increase in the overall results of the batches of students exposed to IT unlike to those who were not exposed to the same (Table 2).
Table 2: First year MBBS University examination results in Anatomy in the last six years. |
| Year |
Result (In Percentage) |
2009 |
92.8 |
2010 |
92.7 |
2011 |
95 |
2012 |
96 |
2013 |
97.2 |
2014 |
98 |
Discussion
Medical education strives to improve and maintain the quality of health care delivered by doctors to patients. This process is directly related to the quality teaching in medical colleges.(7) There is a growing concern among medical teachers that conventional teaching methods fail to bring out the right qualities in the students. Most medical colleges in India have traditional teacher-centered and hospital based training.
Six education strategies have been identified relating to the curriculum in a medical school. Each issue can be represented as a spectrum or continuum: student-centred/teacher-centred, problem-based/information-gathering, integrated/discipline-based, community-based/hospital-based, elective/uniform and systematic/apprenticeship-based. This is popularly called as the SPICES model of curriculum. This SPICES model of curriculum strategy analysis can be used in curriculum planning or review, in tackling problems relating to the curriculum and in providing guidance relating to teaching methods and assessment.(4)
There are four major components in IT namely Integration of experience, social integration, integration of knowledge and integration as a curriculum design.(8) IT is an important strategy to promote meaningful learning and make it last for a longer time; integration helps to efficiently recall knowledge when required.(9) It connects skills and knowledge and thus bridges the gap between academic knowledge and practicals.(1) To improve the quality of students and to have effective diagnosis and better treatment of the patients, integrated learning is the need of hour. In recent years throughout the world such curricula have been used by faculties to teach the students.(10-13)
The present study revealed that the average marks obtained by students after an integrated teaching approach was greater than the marks obtained by students after the conventional teaching methods. Few other Indian studies have also confirmed the same.(14,15) Students trained with integrated curriculum were more accurate in diagnosis of the clinical disorders than those trained in a conventional curriculum.(16) IT improves the cognitive and psychomotor domains of students and creates interest in topics and eliminates the fear toward the subject. The study by Schmidt et al did not take into account the feedback of the students and faculty on the integrated teaching.(16) However in the present study a positive feedback was obtained from the students, who insisted that IT should be a part of the teaching curriculum. This was in general agreement with Studies by Kate et al who showed that this teaching–learning method was welcomed with great enthusiasm both by students and faculty.(14) The present study also stresses on sensitizing the faculty for effective implementation of the curriculum.
The Medical Council of India (MCI) currently stresses on the need based curriculum to create interest among the students.(5) In order to meet this end, the MCI in its amendment 2012 has recommended the integrated teaching method and also strives to make it a part of regular curriculum.(17) The same has been efficaciously practiced in our institution.
Case presentations: In problem-based learning (PBL) courses, students work with classmates to solve complex and authentic problems that help develop content knowledge as well as problem-solving, reasoning, communication, and self-assessment skills. These problems also help to maintain student interest in course material because students realize that they are learning the skills needed to be successful in the field. Case presentation, as practiced in our department is a novel form of PBL. Overall, PBL is an effective method for improving students’ problem-solving skills. Students will make strong connections between concepts when they learn facts and skills by actively working with information rather than by passively receiving information.(18,19) Although active learning requires additional work on the part of students and faculty, Kingsland observed that students find PBL courses satisfying.(20) However in the present study the students stated that although PBL s are useful, they should not be conducted close to their examinations as it involves a lot of additional work and time and thus may affect their performance in examinations.
Guest lectures by clinical faculty: Yet another innovative method introduced in the IT program exposed the students to clinical scenarios well in advance during their pre-clinical course of study. This was incorporated in order to make the students understand the importance of the pre-clinical subjects in their clinical career. The topics were chosen in such a way that they are correlated to the particular preclinical topic which is been taught. This enticed the students to study the pre-clinical subjects with greater interest which was confirmed by their feedback.
Video demonstrations: Dissection class is a must and an integral part of the anatomy teaching curriculum. In our institution, in addition to the conventional dissection classes, students are allowed to revise using the dissected specimens. Revision classes in the form of video demonstrations are also regularly practiced. This method of learning is unique and is seldom practiced in majority of the medical institutions. Feedback revealed that video demonstrations deepened their understanding of anatomical structures, provided them with a three-dimensional perspective of structures and helped them recall what they learnt and therefore should be frequently practised in the curriculum. Authors in the past have suggested the incorporation of routine dissection in an integrated problem-based learning medical course, stating its benefits.(21) The present study agrees with the same. This was ascertained by positive feedback from the students and progressive examination results.
Conclusion
IT is an advanced method to strengthen the teaching-learning process and has had a positive response from the student population. Integration between preclinical and clinical subjects plays a crucial role not only in learning experience but also for better problem solving in clinical practice. The present study analyzes the positive effects of IT and also forms a baseline upon which an integrated and clinically oriented assessment pattern could be implemented in the curriculum. IT can be enhanced by including case presentations by students, lectures by clinical faculty followed by discussion and video demonstrations of dissected specimens which is effectively being followed in our institution.
Conflict of Interest: None declared
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