15 Using an integrated and inter-professional approach
Definition
The term ‘horizontal integration’ is used to describe the bringing together of subjects in the same phase of the curriculum. ‘Vertical integration’ is applied to the integration of subjects normally taught in different phases of the curriculum. Traditionally, the early years of the medical course were devoted to the study of the basic medical sciences. More recently we have seen, as described in Chapter 11, the introduction of clinical learning opportunities into the earlier years and the basic sciences related to this. More attention needs to be
Fig 15.1 A comparison between how subjects are covered in a discipline-based and integrated curriculum.
paid to the integration of the basic sciences with clinical medicine in the later years of the curriculum.
Advantages of integration
• Integrated teaching reflects the practice of medicine. An integrated approach, more than a discipline-based approach, encourages the student to take a holistic view of the patient and his or her problems. In a final examination in a medical school that had a discipline-based curriculum we observed that a student, when asked to take a history from a woman with abdominal pain, enquired whether he should take a medical, surgical or gynaecological history. He had clearly failed to integrate what he had learned in the different clinical attachments.
• Integration motivates the students. Most students are not interested in becoming anatomists or physiologists and the relevance of the basic sciences to the practice of medicine may not be appreciated by them. The traditional curriculum, sadly, was often associated with a decrease in the early years in the students’ enthusiasm and interest in medicine.
• Integration by relating theory to practice makes learning more effective. The ability to retrieve an item from memory depends on the similarity between the condition in which it was learned and the context in which it is to be retrieved. In the classic diver experiment, divers learned from a text underwater and on the surface. When tested subsequently on the surface they performed better on the text learned on the surface. When tested underwater they performed better on the text they had learned underwater. This has been replicated in many other studies. It is also recognised that knowledge learned in isolation and not applied is easily forgotten – so called ‘inert’ knowledge.
• An integrated curriculum can help to avoid unnecessary re-duplication. An integrated curriculum highlights what is important for the student to know and can be seen as a response to the problem of information overload.
• The integrated curriculum may be more cost effective. Greater efficiency can be achieved by sharing teaching and learning resources such as the facilities in a clinical skills laboratory.
• An integrated approach promotes collaboration and communication between staff. An integrated approach requires a discussion between staff as to how each subject can contribute to the learning outcomes. Staff who collaborate in their teaching may go on to collaborate in their research activities.
Focus for integration
The focus for integration may be:
• The body systems. This is the most commonly adopted approach in the early years of the medical course with students studying, for example, a 6-week course on the cardiovascular system, a 5-week course on the respiratory system, etc.
• The life cycle. A focus for the integration may be the life cycle including the newborn, the child, the adolescent, the adult, the elderly and death. This may be used in conjunction with a system-based approach.
• Clinical presentations or a set of descriptions of the tasks facing a doctor. Task-based learning as described in Chapter 14 and in Appendix 3 is a useful approach to integration, particularly in the later years of the course (Harden et al 2000).
The integration continuum
Discussions about integration have been polarised with some teachers arguing in favour and others against integrated teaching. In the SPICES model for educational strategies, integration is presented as a continuum with full integration at one end and discipline-based teaching at the other (Harden 2000). Any position between the two extremes may be adopted as described on the integration ladder (Fig. 15.2). The most appropriate level to suit a particular curriculum can be identified.
