integrated curriculum.pptx

Integrated Medical Curriculum Olfat Fawzy Eman Mahmoud Omaima abul kheir Asmaa Madbouly Asmaa Aly Group 1

OBJECTIVES Define integration Outline the different models of integration Recognize the benefits Identify the advantages & disadvantages

Traditional vs Integrated Education

History Abraham Flexner Recommendations M edical curricula around the world came to be structured into: Preclinical medicine : learned in lecture theatres, teaching laboratories, dissecting rooms & libraries Clinical medicine: learned in wards and operating theatres of university tertiary hospitals (1866–1959)

History

Essential Questions What are some major benefits of integrating curriculum? What are the criticisms of integrated curricula? How can curriculum integration be used to motivate students and incorporate standards more efficiently? How does curriculum integration and professional development support student achievement?

What is Integration?? Think, Pair & Share

2 Disciplines should integrate their contributions into a thematic, probably systems-based curriculum Why????

Learn like doctor & think like doctor H uman beings are complex organisms whose separate systems are linked intricately within the body and modified greatly by external influences W e need to teach in ways that reflect this complexity & that stimulate students to synthesize information across disciplines. Dienstag

Learn like doctor & think like doctor A sick patient does not represent a biochemistry problem, an anatomy problem, a genetics problem, or an immunology problem. Each person is the product of numerous molecular, cellular, genetic, environmental, and social influences that interact in complex ways to determine health and disease. Dienstag

Integration: definition The teaching of different subject areas in a thematic manner, so that the different disciplines are not emphasized. ”Internal dictionary of Adult & CME

Integration: Definition ‘‘The organization of teaching matter to interrelate or unify subjects frequently taught in separate academic courses or departments’’ (Harden et al. 1984)

Harden’s Integration Ladder

Models of Curriculum Integration Horizontal integration Vertical integration Spiral integration

Advantages of Integrated Curriculum

Disa dvantages of Integrated Curriculum

S teps in creating integrated curriculum 3. Decide what goals, questions & criteria to use 1. Decide on a conceptual design framework 2. Create a vision of the learners at the end of the process 4. Develop assessments to match the content & fit into the end vision of the learner. 5. Decide on how to deliver or implement the curriculum 6. Reflect, evaluate & revise using the collaborative process

29 Curriculum Integration

Differences in integrated & discipline-based curriculum??

Horizontal integration Model Defined as integration across disciplines but within a finite period of time. Eg integration in the basic sciences, into a unified, ‘‘interdisciplinary blocks’’ year-long introductory course before students begin their clinical learning .

Vertical integration Model Vertical integration represents integration across time, attempting to improve education by disrupting the traditional barrier between the basic and clinical sciences. Examples include the ‘‘Z-shaped curriculum model’’

Spiral integration . Integration in its most ideal form might then represent a combination of both horizontal and vertical integration, uniting integration across time and across disciplines. ‘‘spiral integration’’,is recently defined as a curriculum involving ‘‘learning both sciences [basic and clinical] across both time and subject matter’’ ( Bandiera et al. 2013). In this model, foundational and clinical sciences interact equally throughout all phases of a curriculum, with common themes uniting the two as participants progress from students to physicians. This model was introduced in response to the GMC’s call for ‘‘true integration of the course, both horizontal and vertical, using the term in the sense of interdisciplinary synthesis and not simply coordination or synchronization of departmentally based components’’ (GMC 1993). Themes such as clinical methods, ethics, and health promotion run throughout all years of the curriculum – bringing the model into a more modern era by emphasizing the broader concept of the clinical sciences deemed more relevant to physician success.

Using unified definitions Utilizing the spiral model as the ideal goal, we propose that ‘‘integrated curriculum’’ be defined as: a fully synchronous, trans-disciplinary delivery of information between the foundational sciences and the applied sciences throughout all years of a medical school curriculum.

The rationale for the separate-subject approach has most often been based on the philosophy that the purpose of education is to master facts, principles, and skills in a specific content area. Proponents of integrated curriculum hold to the belief that the mastering of facts is secondary to making curriculum meaningful through the integration of subject areas and problem-solving.

Advantages & Disadvantages??

Principles of Adult learning? The need to know — adult learners need to know why they need to learn something before undertaking to learn it Learner self-concept — need to be responsible for their own decisions Role of learners' experience — have a variety of experiences of life - the richest resource for learning Readiness to learn — are ready to learn those things they need to know in order to cope effectively with life situations Orientation to learning — are motivated to learn to the extent that they perceive (=see, notice) that it will help them perform tasks they confront (challenge) in their life situations.

The Rationale Curriculum organization denotes a systematic arrangement of curriculum elements. It results in a more relevant, meaningful, and student-centered curriculum. Integration makes the learning contexts close to the context in which the information is to be retrieved e.g. integrated learning within integrated context such as primary care medicine.

Educational theories and Adult learning theory: Adult learners are willing to invest time learning a topic only after they understand the topic’s relevance. In medical education, basic science details are difficult to connect to clinical scenarios for beginning learners with limited or no clinical exposure This challenge is overcome by linking basic science material to clinical problems, often through patient-based or case-based learning. Cognitive psychology learning theory: knowledge is most effective when organization of that knowledge matches the way in which it is to be used. Thus, teaching medical students about basic science in the context of clinical examples and explicitly making connections among concepts through integrated presentation of material are two ways that integration can enhance long-term retention and deeper understanding. Cognitive psychology about transfer of learning: Using comparisons of clinical examples can help students identify deep features of basic science concepts that will help them elaborate on that knowledge as they progress into clinical education.

Educational theories supporting integration Bloom et al. (1956) describes learning as having three domains: cognitive, psychomotor, and affective. These three domains might better be tailored to current formats of medical education if defined instead as knowledge, skills, and attitudes. Traditional fragmented curricula develop the first domain, knowledge, in the classroom before allowing students the opportunity to develop the second domain, clinical skills; students are ideally exposed to the ‘‘attitudes’’ of medical practice (professionalism, ethics, etc.) throughout their education, either in the classroom or in practice.

Integration: Challenge and Opportunities The real challenge of integration is how to transition from fragmented delivery to a synthesized delivery of these three domains throughout a medical curriculum. Integration has come into favor with the hope that combining the delivery of information will increase efficiency and promote retention and ease of application. This is accomplished through repetitive discussion and progressive development of concepts.

Educational models supporting this concept ‘‘ICE’’ Students are first introduced to foundational concepts (ideas) Then they connect or incorporate them with other learning (connections) to develop a fundamental conceptual framework. Learners then apply the concepts to real-life examples (extensions). Costate-Young & Wilson 2000

Implementing integration Creating an integrated curriculum can be time consuming and resource-intensive. No ideal ‘‘instruction manual’’ exists, but knowledge of theory and models along with review of literature offer excellent starting points. In addition, publications reviewing novel integrated curricular projects are often accompanied by discussion of the challenges and tips for revisions necessary for success One strategy that is likely to be of particular assistance to those revising a curriculum is mapping, reviewed by Harden in a separate AMEE Guide (Harden 2001).

Curriculum mapping ‘‘Curriculum mapping is concerned with what is taught (the content, the areas of expertise addressed, and the learning outcomes), how it is taught (the learning resources, the learning opportunities), when it is taught (the timetable and the curriculum sequence) and the measures used to determine whether the student has achieved the expected learning outcomes (assessment)’’. Mapping offers two key functions: (1) making the curriculum more transparent and (2) demonstrating links within the curriculum. Of particular relevance for this discussion are the links between expected learning outcomes, the curriculum content, and student assessment.

Advantages Matching curriculum aims Achieving higher level of objectives Avoiding information overload Making learning interesting & effectives Motivating students Benefiting staff

Actions for Integrating Curriculum Integration

16 Some background on Students learning

Disadvantages Loosing subject identity Requiring interdepartmental planning Resources shortage Contents coverage Motivating students

Summary Learning take place better if it is contextual. Overcrowding information could be solved by integration. Integration is the necessity & not the luxury. This is the relatively new trend which has been applied in medical education every where.

3 What is a curriculum?? a curriculum?? 4 What is a curriculum?The curriculum is the set of courses and their content offered at a school or university with which students will interact for the purpose of achieving identified educational outcomes.The curriculum is the set of instructional strategies teachers plan to use. 5 What is a curriculum?A curriculum is about what should happen in a teaching program – about the intension of the teachers and about the way they make this happen.The curriculum in fact isWhat the student learnsHow the student learns (strategy/s & Learning/teaching tools)How the student assessedThe learning environmentLearning outcomes 6 Types of Curricula The Concurrent Curricula The official curriculum: (The written curriculum),The Operational Curriculum,Hidden Curriculumis a side effect of an education, which are learned but not openly intended such as the transmission of values, and beliefs conveyed in the classroom and the social environment. 7 Different curricular models Outcome-Based Education (OBE)- What sort of doctor is needed?philosophy that focuses on measuring student performance, which are called outcomes. Students demonstrate that they have learned the required skills and contentOBE contrasts with traditional education which primarily focuses on the resources that are available to the student, which are called inputs. 8 Different curricular models Problem-Based Learning (PBL)is a student-centered education in which students learn about a subject in context of complex, many-sided & realistic problemsThe goals of PBL are to help students:develop flexible knowledge,effective problem solving skills,self -directed learning (SDL),effective collaboration skills &intrinsic motivation 9 Different curricular models Problem-Based Learning (PBL)Working in groups,students identify what they already know, what they need to know, & how & where to access new information that may lead to resolution of the problem.The role of the instructor is facilitator who provides appropriate support, modeling of the process, & monitoring the learning 10 Different curricular models Task-Based Learning:The primary focus of classroom activity is the task and information the students have, is the instrument which the students use to complete it. 11 Different curricular models Core & Student selection ComponentsAn Integrated system-based approach.Community -Based Educationlearners are encouraged to actively apply concepts & information, skills or attitudes to local situations. E.g. students would not just study pollution, but would be encouraged & provided with the opportunity to observe, examine and hopefully reverse pollution of pond water at local levels through a variety of actions. 12 Basic curricular structures The discrete (=separate, isolated) curriculum,The linear curriculum,The pyramidal structure, ANDThe spiral curriculum.Curriculum in which students repeat the study of a subject at different grade levels, each time at a higher level of difficulty and in greater depth. 13 Educational strategies Six educational strategies by Prof Harden.Each strategy can be represented as a spectrum or continuum:Student-centered /teacher- centeredProblem -based/information- gatheringIntegrated /discipline- basedCommunity -based/hospital- basedElective / uniformSystematic /apprenticeship (internship)-based 14 SPICES Model of Educational Strategies Hospital- basedSPICES Model of Educational StrategiesStudent centered“What the student learn rather than what is taught"Teacher centeredProblem-basedInformation-orientedSubject or Discipline- basedIntegrated or Inter- professionalIntegration throughout the curriculumCommunity-basedLess emphasis on hospital-based programsHospital -based 15 SPICES Model of Educational Strategies Hospital- basedSPICES Model of Educational StrategiesElective-drivenAccording to student needs, learning & teaching adjusted to the needs of studentsUniformSystematicTo ensure that all students have had comparable learning experienceapprenticeship (internship)- basedi.e Opportunistic (=resourceful) 16 Some background on Students learning 17 Principles of Adult learning? The need to know — adult learners need to know why they need to learn something before undertaking to learn itLearner self-concept — need to be responsible for their own decisionsRole of learners' experience — have a variety of experiences of life - the richest resource for learningReadiness to learn — are ready to learn those things they need to know in order to cope effectively with life situationsOrientation to learning — are motivated to learn to the extent that they perceive (=see, notice) that it will help them perform tasks they confront (challenge) in their life situations. 18 Think, Pair & Share:What is Integration?? 19 Abraham Flexner Recommendations: Under Flexner’s influence, medical curricula around the world came to be structured into:Preclinical medicine: learned in lecture theatres, teaching laboratories, dissecting rooms, and librarieClinical medicine: learned in wards and operating theatres of university tertiary hospitals 20 In the late twentieth century, national bodies began to respond to the wind of change to meet patients’ needs to be achieved through curriculum integration. 21 Disciplines should integrate their contributions into a thematic, probably systems-based curriculum 22 Integration was one of the key criteria for assessing the degree of innovation in a medical curriculum in the SPICES curriculum model (Harden, 1984). 23 Old Curriculum Basic Sciences: Anatomy Physiology Pathology/Immunology/Microbiology…. BiochemistryPharmacologyClinical:Medicine , surgery, Ob/Gyn, Peadiatrics,ENT / Oph …. 24 Learn like doctor & think like doctor …because human beings are complex organisms whose discrete (=separate) systems are linked intricately (=complicatedly) and elaborately within the body and modified profoundly (=greatly) by external influences, we need to teach in ways that reflect this complexity and that stimulate students to synthesize information across disciplines.Dienctag 25 Learn like doctor & think like doctor A sick patient does not represent a biochemistryproblem , an anatomy problem, a geneticsproblem , or an immunology problem; rather,each person is the product of myriad (=numerous) molecular, cellular, genetic, environmental, and social influences that interact in complex ways to determine health and disease.Dienctag 26 What is Integration?? 27 Integration: a definition “ The teaching of different subject areas in a thematic manner, so that the different disciplines are not emphasized”Internal dictionary of Adult & CME 28 Integration: a definition “ The organization of teaching of matter to interrelate or unify (join, unite) subjects frequently taught in separate academic courses or departments”Harden 29 CurriculumIntegration 30 Curriculum: What is taught in a school 31 Think, Pair & Share: Differences in integrated & discipline-based curriculum?? 32 The Rationale (= basis,foundation ) Curriculum organization denotes (=means) a systematic arrangement of curriculum elements.It will results in a more relevant, meaningful, and student centered curriculum.Integration makes the learning contexts close to the context in which the information is to be retrieved (=recovered, regained). E.g. integrated learning within integrated context such as primary care medicine. 33 Think, Pair & Share: Advantages & Disadvantages?? 34 Advantages 1. Matching curriculum aims. 2. Achieving higher level of objectives.3. Avoiding information overload.4. Making learning interesting & effectives5. Motivating students.6. Benefiting staff. 35 Disadvantages 1. Loosing subject identity. 2. Requiring interdepartmental planning.3. Resources shortage.4. Contents coverage.5. Motivating students. 36 Types of Integration Clinical Basic Science Horizontal Integration Vertical integrationHorizontal Integration 37 Summary 38 Summary Learning take place better if it is contextual. Overcrowding information could be solved by integration.Integration is the necessity & not the luxury.This is the relatively new trend which has been applied in medical education every where. 39 I wish you a very successful and enjoyable time in your course All the best

Types of Integration Clinical Basic Science Horizontal Integration Vertical integration Horizontal Integration

“E ducation that is organized in such a way that it cuts across subject matter lines, bringing together various aspects of the curriculum into meaningful association to focus upon broad areas of study.”

There is an ongoing discussion about whether medical curriculum should be discipline based or integrated. The method of teaching medicine, since Flexner's days, implies that students should first learn basic and biomedical sciences and then move to clinical sciences; however, this is not how patients are presented. A common criticism of this approach is that students will not see the relevance of basic and biomedical sciences applied to clinical practice, and it is preferable to encourage students to think as doctors from the day they enter medical school.

Integration is therefore of key importance for medical education because basic science learning is placed in the context of clinical and professional practice and is considered by students to be more meaningful and relevant. In the vast majority of curriculum reforms, vertical integration combines basic and clinical sciences, early clinical experience, clinician–scientist partnerships, and incorporation of sciences in the later years of the course. This is undoubtedly an advantage but is based on a biologist's vision of the health-illness process.

The medical curriculum has historically changed with the definition of health and illness. From the definition of disease as an anatomical alteration of the organs in the eighteenth century to the understanding of its multicausality and influence on lifestyles, the social determinants and social, political, and economical realities of defining health disease as a biological, social, and cultural (historic) process were considered. According to the authors of this article, vertical integration should include not only basic and clinical sciences but also sociohumanistic and population health sciences, leading to a broader conception of ways to teach and learn medicine.

Aware of the limitations emerging from biologist-based medical curricula, the medical school at Rosario University, Colombia, undertook a significant curriculum reform to improve students’ knowledge integration to meet the more complex demands of the health system. With a view toward facilitating this integration, this article aims to present the design and implementation of our integrated curriculum in the past three years and to discuss the advantages and disadvantages faced in this endeavor. It will offer some considerations and implications of curriculum integration.

Definition of Integration The most prominent models for integration discussed over the past few decades were the Integration Ladder introduced by Ronald Harden et al. [1] and the Ten Ways to Integrate Curriculum described by Robin Fogarty et al. [2]. Those two most common continuums of methodologies for integration will be discussed in our review (Figure 1). Figure 1: Rights ISSN:IPR an open access journal V

Definition of Integration Shoemaker et al. defined an integrated curriculum as “education that is organized in such a way that it cuts across subject-matter lines, bringing together various aspects of the curriculum into meaningful association to focus upon broad areas of study”. It views learning and teaching in a holistic way and reflects the real world, which is interactive. In the integrative curriculum, the planned learning experiences not only provide the learners with a unified view of commonly held knowledge but also motivate and develop learners' power to perceive new relationships and thus to create new models, systems, and structures.

Definition of Integration Curriculum integration can be described as an approach to teaching and learning that is based on both philosophy and practicality. It can generally be defined as a curriculum approach that purposefully draws together knowledge, skills, attitudes and values from within or across subject areas to develop a more powerful understanding of key ideas. Curriculum integration occurs when components of the curriculum are connected and related in meaningful ways by both the students and teachers.

Definition of Integration Horizontal integration brings together the disciplines, topics, and subject. It refers to the provision of learning within the structure where individual departments/subject areas contribute to the development and delivery of learning a meaningful, holistic manner. By this process and links are made between the different subject areas and that learning is enriched by the connections and interrelationships being made explicit.

Definition of Integration Vertical integration brings together basic and clinical sciences. It refers to combination of basic and clinical sciences in such a way that the traditional divide between preclinical and clinical studies is broken down, therefore basic science is represented explicitly in the curriculum within the clinical environments during all the years of undergraduate education and beyond into postgraduate training and continuing professional development. This means that the learning of basic science is placed in the context of clinical and professional practice and seen to be more meaningful and relevant to students. Curriculum integration usually involves both horizontal and vertical integration and is the pattern that is becoming widespread throughout the world.

Background Integration is around us everywhere in society and in nature. Most contemporary jobs require the integration of a range of skills. In today’s workforce, we are given a problem and asked to solve it. In traditional schools students are given a set of facts, asked to memorize them, but then are not given the opportunity to apply them in a way that is applicable to life outside of the school. Disconnection breeds apathy while integration thrives on connections. The movements toward a global economy and international connections, as well as the rapid changes in technology, are pushing education toward integration. The ability to make connections, to solve problems by looking at multiple perspectives, and to incorporate information from different fields, will be an essential ingredient for success in the future.

Integration represents a way to avoid the fragmented and irrelevant acquisition of isolated facts, transforming knowledge into personally useful tools for learning new information. Integrated curricula have been widely adopted, fuelled by dissatisfaction with the way basic sciences have been taught as individual disciplines with no clinical application and by growing recognition that the traditional instructional modes no longer meet current demands for interdisciplinary inquiry and practice in medicine. At the same time, cognitive theories of learning suggest that an integrated approach to education may have important benefits for learning and retention because it facilitates contextual and applied learning, and can promote development of the well-organized knowledge structures that underlie effective clinical reasoning. Traditional pre-clerkship curricula, with each science discipline offering its content from within a departmental silo, frequently fail learners as they advance to the clinical years.

Information presented without robust cross-links and ties to clinical applications, and tested in isolation from related subject matter, has proven difficult for students to recall after the transition to clinical clerkships. The movement towards integrated curriculum is a move away from memorization and recitation of isolated facts and figures to more meaningful concepts and the connections between concepts. The twenty-first century requirement for a flexible use of knowledge goes beyond a superficial understanding of multiple isolated events to insights developed by learning that is connected-(Or) integrated. History Since the time of Flexner, the basic science medical school curriculum has largely consisted of discrete courses controlled by individual departments [8]. Such curricula have largely included an initial phase focused on normal structure and function followed by a pathophysiology phase, sometimes organized around organ systems or taught during core clinical rotations [15]. Dissatisfaction with this curricular model has included students’ complaints about lack of relevance and faculty members’ concerns about students’ failure to recall relevant basic science knowledge during their clinical education. Medical students have viewed the basic science curriculum as a hurdle to be overcome in order to earn the right to step onto the hospital wards and clinical teachers have complained that when students arrive on the clinical rotations, they have no intellectual curiosity, having spent the first phase of medical school memorizing unrelated facts rather than learning to think like a clinician [15].

In 1969, McMaster Medical School challenged the assumption that

Background Integration is around us everywhere in society and in nature. Most contemporary jobs require the integration of a range of skills. In today’s workforce, we are given a problem and asked to solve it. In traditional schools students are given a set of facts, asked to memorize them, but then are not given the opportunity to apply them in a way that is applicable to life outside of the school. Disconnection breeds apathy while integration thrives on connections [6]. The movements toward a global economy and international connections, as well as the rapid changes in technology, are pushing education toward integration. The ability to make connections, to solve problems by looking at multiple perspectives, and to incorporate information from different fields, will be an essential ingredient for success in the future. An enduring argument for integration is that it represents a way to avoid the fragmented and irrelevant acquisition of isolated facts, transforming knowledge into personally useful tools for learning new information [7]. Integrated curricula have been widely adopted, fuelled by dissatisfaction with the way basic sciences have been taught as individual disciplines with no clinical application and by growing recognition that the traditional instructional modes no longer meet current demands for interdisciplinary inquiry and practice in medicine [8,9]. At the same time, cognitive theories of learning suggest that an integrated approach to education may have important benefits for learning and retention because it facilitates contextual and applied learning, and can promote development of the well-organized knowledge structures that underlie effective clinical reasoning [10-13]. Traditional pre-clerkship curricula, with each science discipline offering its content from within a departmental silo, frequently fail learners as they advance to the clinical years. Information presented without robust cross-links and ties to clinical applications, and tested in isolation from related subject matter, has proven difficult for students to recall after the transition to clinical clerkships [14]. The movement towards integrated curriculum is a move away from memorization and recitation of isolated facts and figures to more meaningful concepts and the connections between concepts. The twenty-first century requirement for a flexible use of knowledge goes beyond a superficial understanding of multiple isolated events to insights developed by learning that is connected-(Or) integrated [4]. History Since the time of Flexner, the basic science medical school curriculum has largely consisted of discrete courses controlled by individual departments [8]. Such curricula have largely included an initial phase focused on normal structure and function followed by a pathophysiology phase, sometimes organized around organ systems or taught during core clinical rotations [15].

modes no longer meet current demands for interdisciplinary inquiry and practice in medicine [8,9]. At the same time, cognitive theories of learning suggest that an integrated approach to education may have important benefits for learning and retention because it facilitates contextual and applied learning, and can promote development of the well-organized knowledge structures that underlie effective clinical reasoning [10-13]. Traditional pre-clerkship curricula, with each science discipline offering its content from within a departmental silo, frequently fail learners as they advance to the clinical years. Information presented without robust cross-links and ties to clinical applications, and tested in isolation from related subject matter, has proven difficult for students to recall after the transition to clinical clerkships [14]. The movement towards integrated curriculum is a move away from memorization and recitation of isolated facts and figures to more meaningful concepts and the connections between concepts. The twenty-first century requirement for a flexible use of knowledge goes beyond a superficial understanding of multiple isolated events to insights developed by learning that is connected-(Or) integrated [4].

History Since the time of Flexner, the basic science medical school curriculum has largely consisted of discrete courses controlled by individual departments [8]. Such curricula have largely included an initial phase focused on normal structure and function followed by a pathophysiology phase, sometimes organized around organ systems or taught during core clinical rotations [15]. Dissatisfaction with this curricular model has included students’ complaints about lack of relevance and faculty members’ concerns about students’ failure to recall relevant basic science knowledge during their clinical education. Medical students have viewed the basic science curriculum as a hurdle to be overcome in order to earn the right to step onto the hospital wards and clinical teachers have complained that when students arrive on the clinical rotations, they have no intellectual curiosity, having spent the first phase of medical school memorizing unrelated facts rather than learning to think like a clinician [15]. In 1969, McMaster Medical School challenged the assumption that students could only learn basic science by listening to the experts; faculty replaced the traditional lecture and laboratory basic science curriculum with problem-based learning (PBL) in which small groups of students working with cases and problems under the guidance of a faculty tutor could be trusted to identify essential learning questions and educate themselves through independent and peer teaching [16]. Few medical schools in North America were willing to adopt this curricular model until Harvard Medical School created a hybrid curriculum in 1985 that combined PBL with limited lectures and laboratories in order to help students develop a flexible, integrated knowledge base [17]. Using a block structure rather than concurrent courses to promote integration and encouraging partnerships between basic science and clinical faculty members in designing these blocks, Harvard demonstrated that students could learn basic science in the context of clinical medicine and humanistic care while maintaining sufficient content mastery to pass the national licensing examination with no decrement in basic science knowledge [18]. The prevailing trend in basic science curriculum change around the world is now towards integration, both horizontally among disciplines and vertically between basic and clinical sciences, often including PBL as an integrative function [19].

“Curriculum integration facilitates the pursuit of new knowledge and meaning by transcending the disciplines of knowledge rather than abandoning them.” —James A. Bean

Benefits of Integrative Approach to Curriculum Planning Many teachers in the primary grades cite the following benefits of an integrative approach to curriculum and planning. Allowing for flexibility: Through curriculum integration, teachers can plan for the development of key skills and understandings that transcend individual strands and subjects. Building on prior knowledge and experiences: Choosing meaningful connections among subject areas helps students build on their diverse prior knowledge and experiences, supports their holistic view of the world and ensures more meaningful learning. Unifying the students’ learning Curriculum integration enables students to develop a unified view of the curriculum to broaden the context of their learning beyond single subject areas. Reflecting the real world When curriculum is organized in a holistic way, it better reflects the real world and the way children learn at home and in the community Matching the way students think: Brain research supports the theory that younger students take in many things and process and organize them at one time. Teaching ideas holistically, rather than in fragmented pieces, better reflects how young students’ brains process information [5]. Requirements for Integration 1. Effective management of change: Shifting the curriculum from one state (fragmentation) to another (integration) is a major issue needs careful management by the curriculum administrators and also needs full understanding and support by everyone in the institution. 2. In-depth review the curriculum: to be able to plan and implement a successful integration in the curriculum, every component of the curriculum and every curriculum area should be properly mapped and documented. 3. Commitment of faculty, departments, and individuals, and development of teams and structures to support planning and implementation. 4. Agreement on the degree and type (horizontal and vertical) of integration: the level of integration should be agreed upon by faculty, departments, and individuals based on the feasibility and resources available. Sometimes, partial integration is better adopted as a beginning and the level can be increased gradually by time. This is true especially in well-established institutions. In newly-established ones, a fully integrated curriculum may be planned from the beginning; so long the resources are available. Also, integration may be started as horizontal in the basic medical sciences as a prototype for further integration (horizontal between clinical sciences and vertical between basic and clinical sciences) [6]. Methodologies of Integration In this paper, the two most common continuums of methodologies for integration [1,2] will be described. Fogarty methodologies for integration: Fogarty et al. [2] has described ten levels of integration, grouped under three forms. Form One: Within a Single Discipline Fragmented 1. Description: The fragmented methodology is a traditional curriculum design which separates topics and courses into distinct disciplines. In this model courses are separated into traditional areas of study. Each area is defined as an independent course of study. 2. Advantages: Clear and discrete view of a discipline to the students. 3. Disadvantages: Connections are not made clear for students; less transfer of learning. Connected 1. Description: A connected methodology focuses on the details, subtleties, and interconnections within an individual discipline. It is this focus on making connections (i.e., one topic to another, one skill to another or one concept to another) which makes this methodology a simple form of integration. It is important to the concept of integration that this methodology directly relates ideas within a discipline. 2. Advantages: Key concepts are connected leading to the review, reconceptualization, and assimilations of ideas within a discipline. 3. Disadvantages: Disciplines are not related; contents focus remains within the discipline. Nested 1. Description: Nested integration takes advantage of natural combinations. Integration is performed by overtly making connections or creating combinations. 2. Advantages: Gives attention to several areas at once, leading to enriched and enhanced learning. 3. Disadvantages: Students may be confused and lose sights of the main concepts of the activity or lesson. Form Two: Across the Disciplines Sequenced 1. Description: Topics and units are taught independently, but they are arranged and sequenced to provide a framework for related concepts. Teachers arrange topics so that similar units articulate. 2. Advantages: Facilitates transfer of learning across content areas. 3. Disadvantages: Requires ongoing collaboration and flexibility, as teachers have less autonomy in sequencing curricula. Shared 1. Description: The shared model brings two distinct disciplines together into a single focus. The shared methodology overlaps concepts as the organizer. 2. Advantages: Shared instructional experiences; with two teachers on a team it is less difficult to collaborate. 3. Disadvantages: requires time, flexibility, commitment and compromise. Webbed 1. Description: Thematic teaching, using a theme as a base for instructions in many disciplines. 2. Advantages: Motivating for students; helps them see connections between ideas. 3. Disadvantages: Theme must be carefully and thoughtfully selected to be meaningful, with relevant and rigorous content. Threaded 1. Description: The threaded approach to integration is a metacurricular approach where big ideas are enlarged. This methodology threads thinking skills, social skills, study skills, graphic organizers, technology, and multiple intelligences approach to thinking throughout all disciplines. The threaded approach supersedes all subject matter content. Using this approach, interdepartmental teams can focus on thinking skills to integrate with content information. The threaded approach takes learning to a synthesis level. 2. Advantages: Students learn how they are learning, facilitating future transfer of learning. 3. Disadvantages: Disciplines remain separate. Citation: Atwa HS, Gouda EM (2014) Curriculum Integration in Medical Education: A Theoretical Review. Intel Prop Rights 2: 113. doi:10.4172/ ipr.1000113 Page 3 of 7 Intel Prop Rights ISSN:IPR an open access journal Volume 2

Integrated 1. Description: In an integrated methodology interdisciplinary topics are arranged around overlapping concepts and emergent patterns. This process blends the disciplines by finding overlapping skills, concepts, and attitudes found across the disciplines. Much like the shared methodology, integration is a result of shifting related ideas out of the subject matter content. An important process of the integrated methodology is that teachers work together on the topics or themes as commonalities emerge. 2. Advantages: Encourage students to see interconnectedness and interrelationships among disciplines, students are motivated as they see these connections. 3. Disadvantages: Requires interdepartmental teams with common planning and teaching times. Form Three: Within and Across Learners Immersed 1. Description: The immersed methodology focuses all curricular content on interest and expertise. With this methodology, integration takes place within the learners, with little or no outside intervention. This immersed study is often undertaken in a field of intense interest or passion. 2. Advantages: Integration takes place within the learner. 3. Disadvantages: May narrow the focus of the learner. Networked 1. Description: A networked methodology creates multiple dimensions and directions of focus. Like brainstorming, it provides various ideas and ways of discovering. The networked methodology is totally student centered. It professes that only the learner can direct the integration process. The methodology proposes that the learner knows their topic and can self-direct their focus on the necessary resources both within and across subject areas. 2. Networks are created between the learner and various information systems, subject matter experts, and others who have an interest, experience or knowledge of the topic or theme. 3. Advantages: Pro-active, with learner stimulated by new information, skills and concepts. 4. Disadvantages: Learner can be spread too thin, efforts become ineffective. Harden Methodologies for Integration: “

The Integration Ladder” Harden et al. [1] argues that curricular integration can be viewed as a ladder, with discipline-based teaching (isolation) at the bottom of the ladder and full integration (trans-disciplinary teaching) at the top. Figure 2: The Integration Ladder. (Courtesy of Professor Ronald Harden et al. [1]) The integration ladder (Figure 2) has eleven steps from subject based to integrated teaching and learning. In the first four steps on the ladder, the emphasis is on the subjects or disciplines. Moving up the ladder, the following six steps emphasize integration across several disciplines. In the final step, the student takes more responsibility for the integration and is given the tools to do so [1]. Step 1: Isolation/fragmentation 1. Description: Departments or subject specialists organize their teaching without consideration of other subjects or disciplines. Each discipline looks, from the perspective of their own discipline, at the curriculum content in terms of areas to be covered, depth of coverage, sequence and timing. This isolation approach may be found in the traditional medical curriculum with blocks of time allocated to the individual disciplines. Students attend a lecture on anatomy, and then move on to a lecture in physiology with neither lecturer being aware of what was covered in the other lecture. 2. Advantages: Disciplines are retaining their boundaries so content is kept clear and intact. 3. Disadvantages: No attention is paid to other, or related, subjects which contribute to the curriculum. Each subject is seen as an entity in itself. The relationships between subjects are not explicitly covered and related topics from two disciplines are not intentionally correlated

Step 2: Awareness 1. Description: As with isolation, the teaching is subject-based. However, some mechanisms are in place whereby the teacher in one subject is made aware of what is covered in other subjects in the curriculum. This can be achieved through appropriate documentation and communication about the aims and objectives of each course and the content and topics covered in lectures and other teaching sessions. Lecture notes or handouts may be circulated to other course teachers as well as to students. 2. Advantages: The teacher can take account of what colleagues cover in other parts of the course when planning his or her teaching, avoiding unnecessary duplication or redundancy and cross-referring, where appropriate, to other parts of the course. 3. Disadvantages: There is no explicit attempt to help the student to take an integrated view of the subject. Step 3: Harmonization/consultation 1.

/consultation 1. Description: In harmonization, teachers responsible for different courses or different parts of the same course consult each other and communicate about their courses. The consultation process takes place through informal discussions between teachers or through more formal curriculum planning committees and meetings. The consultation may involve individual teachers or groups of teachers. The process of consultation may be overseen by a member of staff who has some overall responsibility for the curriculum and who has the facilitation or organization of discussion between teachers from different subjects. 2. Advantages: Encourages teachers to adapt their programs so that each course makes an appropriate contribution to the curriculum and the overall curriculum objectives are more likely to be achieved. 3. Disadvantages: Disciplines remain separate. Step 4: Nesting/infusion 1. Description: Content drawn from different subjects in the curriculum may be used to enrich the teaching of one subject. The term “infusion” has also been applied to this stage of integration where teachers “analyze” the separate subject's goals and identify ways in which these generic skills can be refined into existing subjects. 2. Advantages: Individual subjects or disciplines recognize the broader curriculum outcomes and relate their teaching program to these. They may do this by arranging content specific inputs from other parts of the course into the subject's teaching program, and by recognizing the generic competencies, such as communication and problem-solving skills, to be acquired in the program. 3. Disadvantages: Teaching remains subject-based and the course is the responsibility of and in the control of the subject or discipline. Step 5: Temporal co-ordination/parallel teaching 1. Description: Each subject remains responsible for its own teaching program. The timing of the teaching of topics within a subject, however, is done in consultation with other disciplines. The timetable is adjusted so that topics within the subjects or disciplines which are related are scheduled at the same time. Similar topics are taught on the same day or week while remaining part of a subjectbased teaching program. Students study the concepts of the different subjects separately, and are left themselves to uncover the relationships. This approach has been described also as “parallel” or “concurrent” teaching. 2. Advantages: Programs described as “integrated teaching programs” are often, in practice, programs which are temporally coordinated. The implementation of a temporally coordinated program introduces some of the advantages of integrated teaching and is a good stepping off point for a more integrated curriculum. 3. Disadvantages: Teaching is not fully integrated and disciplines still retain, to a great extent, their fragmented nature. Step 6: Sharing/joint teaching 1. Description: Two disciplines may agree to plan and jointly implement a teaching program. The “shared planning and teaching” takes place in two disciplines in which overlapping concepts or ideas emerge as organizing elements'[3]. The two disciplines which come together to offer such a program are usually complementary subjects and the joint course produced emphasizes shared concepts, skills, and attitudes. The focus of the course is usually in these shared elements. The impetus for shared programs often comes from the subjects or departments themselves, through the identification of common areas of teaching or the need to include a new topic in the curriculum. The departments appreciate that together they can teach the subject better, more effectively, and more efficiently than either could alone. 2. Advantages: Unlike temporal co-ordination, which may be a step towards a more fully integrated overall program, shared programs are often seen as ends in themselves. They tend to be perceived as special cases which, even if they are successful, are not necessarily examples to be followed in other parts of the curriculum. Occasionally, however, this is not so and a shared program may be a step towards more complete integration. 3. Disadvantages: Not all disciplines are fit for this type of integration. The two disciplines should have overlapping concepts and ideas. Again, the integration is not fully emphasized here. Step 7: Correlation/concomitant program 1. Description: The emphasis remains on disciplines or subjects with subject-based courses taking up most of the curriculum time. This session brings together areas of interest common to each of the subjects. 2. Advantages: Within this framework, an integrated teaching session or course is introduced in addition to the subject-based teaching. 3. Disadvantages: The integrated disciplines should have areas of common interest. Also, the integration is not fully emphasized, as the emphasis is still on the separate disciplines or subjects. Step 8: Complementary/mixed program 1. Description: This approach has both subject-based and integrated teaching. The integrated sessions now represent a major feature of the curriculum. These sessions are recognized to be, in terms of time, allocated resources and assessment as important, if not more important, than the subject-based teaching. The focus for the teaching may be a theme or topic to which the disciplines can contribute. Running alongside the integrated teaching are scheduled opportunities for subject-based teaching. Citation: Atwa HS, Gouda EM (2014) Curriculum Integration in Medical Education: A Theoretical Review. Intel Prop Rights 2: 113. doi:10.4172/ ipr.1000113 Page 5 of 7 Intel Prop Rights ISSN:IPR an open access journal Volume 2 • Issue 2 • 1000113 2. Advantages: Student assessment strategies in this approach stresses on both the integrated and fragmented parts of the curriculum. 3. Disadvantages: A great part of the curriculum is subject-based, and integration runs as a parallel track alongside the separate disciplines. Step 9: Multi-disciplinary/webbed 1. Description: A multidisciplinary approach (termed “webbed” by Fogarty) brings together a number of subject areas in a single course with themes, problems, topics, or issues as the focus for the students' learning. The themes selected as the focus in an integrated course may function in different ways. The themes can delineate an area in which practical decisions have to be made and which serve as a focal point of interdisciplinary thinking. Tasks to be undertaken by the professional may also be used as a focus for integrated teaching. In task-based learning within this approach, the learning is concerned not only with mastery of the tasks but with learning related to the tasks, including an understanding of the relevant basic and applied medical sciences. In multidisciplinary teaching, the contributions of the individual disciplines to the theme are stated implicitly in the curriculum documents and the timetables. 2. Advantages: The subjects and disciplines give up a large measure of their own autonomy. 3. Disadvantages: The disciplines preserve their identity and each demonstrates how their subject contributes to the student's understanding of the theme or problem. Still, themes are viewed through the lens of subjects or disciplines. Step 10: Inter-disciplinary/monolithic 1. Description: In interdisciplinary integration there is a further shift of emphasis to themes as a focus for the learning of and to the commonalties across the disciplines or subjects as they relate to the theme. Jarvis et al. [20] defines interdisciplinary as `a study of a phenomenon that involves the use of two or more academic disciplines simultaneously (monolithic)'. 2. Advantages: Implicit in the move from a multidisciplinary to an interdisciplinary approach may be the loss of the disciplines' perspectives. 3. Disadvantages: In the interdisciplinary course there may be no reference to individual disciplines or subjects, and subjects are not identified as such in the timetable. Step 11: Trans-disciplinary/authentic/fusion/immersion 1. Description: In trans-disciplinary, as in interdisciplinary integration, the curriculum transcends the individual disciplines. The focus with trans-disciplinary integration for learning, however, is not a theme or topic selected for this purpose, but the field of knowledge as exemplified in the real world. The teacher provides a structure or framework of learning opportunities, but the integration is done in the mind of the student, based on hi-fidelity situations in the real world of clinical care. Trans-disciplinary education is reflected in learning described by McCombs et al. [21] as an individual process of constructing meaning from information and experience, filtered through each individual's unique perceptions, thoughts and feelings.' Thus, in a trans-disciplinary approach the disciplines become part of the learner's real world experience and through these they filter the broader aims and goals of the integrated curriculum. In this environment, the learner is driven to find out as dictated by the prescribed tasks. This stage of integration has been termed `authentic' integration, reflecting that the learning occurs in the real world. The term `fusion' has also been applied to this stage. As the student learns, he or she integrates internally and intrinsically and completes the mastery of the competencies related to the task. Fogarty et al. [22] uses the term `immersion' when `disciplines become part of the learner's experience and through these filter the broader aims and goals'. 2. Advantages: Maximally resembles the real world situations. Experiences learned through it are thought to be easily incorporated into the learner’s metacognition and set of values and attitudes. 3. Disadvantages: it is difficult to achieve and needs tremendous collaborative efforts from the sides of the curriculum planners and subject area experts. Also, its success depends mainly on the learners and their degree of readiness to learn through such highly integrative approach. Conclusion Integrating a curriculum is a complex process. It is differentially understood and experienced by students and faculty, and can refer to instructional method, content, faculty work or synthesis of knowledge in the minds of learners. It can occur at different rates and some subjects are integrated more easily than others. An integrated curriculum holds much promise for raising students, who will be able to apply their school-acquired knowledge to their work and to their personal development. Acknowledgement All praise and gratitude is to Allah. We also would l

3 What is a curriculum?? The curriculum is the set of courses and their content offered at a school or university with which students will interact for the purpose of achieving identified educational outcomes. The curriculum is the set of instructional strategies teachers plan to use.

3 What is a curriculum?? a curriculum? A curriculum is about what should happen in a teaching program – about the intension of the teachers and about the way they make this happen. The curriculum in fact is: What the student learns How the student learns (strategy/s & Learning/teaching tools) How the student assessed The learning environment Learning outcomes

Types of Curricula 6 The Concurrent Curricula The official curriculum: (The written curriculum),The Operational Curriculum, Hidden Curriculum is a side effect of an education, which are learned but not openly intended such as the transmission of values, and beliefs conveyed in the classroom and the social environment. 7

Different curricular models Outcome-Based Education (OBE)- What sort of doctor is needed? philosophy that focuses on measuring student performance, which are called outcomes. Students demonstrate that they have learned the required skills and content OBE contrasts with traditional education which primarily focuses on the resources that are available to the student, which are called inputs. 8

Different curricular models Problem-Based Learning (PBL) is a student-centered education in which students learn about a subject in context of complex, many-sided & realistic problems The goals of PBL are to help students:develop flexible knowledge,effective problem solving skills,self -directed learning (SDL),effective collaboration skills &intrinsic motivation

Different curricular models Problem-Based Learning (PBL)Working in groups,students identify what they already know, what they need to know, & how & where to access new information that may lead to resolution of the problem.The role of the instructor is facilitator who provides appropriate support, modeling of the process, & monitoring the learning

Different curricular models Task-Based Learning: The primary focus of classroom activity is the task and information the students have, is the instrument which the students use to complete it.

Different curricular models Core & Student selection Components An Integrated system-based approach. Community-Based Education learners are encouraged to actively apply concepts & information, skills or attitudes to local situations. E.g. students would not just study pollution, but would be encouraged & provided with the opportunity to observe, examine and hopefully reverse pollution of pond water at local levels through a variety of actions.

12 Basic curricular structures The discrete (=separate, isolated) curriculum,The linear curriculum,The pyramidal structure, AND The spiral curriculum.Curriculum in which students repeat the study of a subject at different grade levels, each time at a higher level of difficulty and in greater depth.

13 Educational strategies Six educational strategies by Prof Harden.Each strategy can be represented as a spectrum or continuum:Student-centered /teacher- centeredProblem -based/information- gatheringIntegrated /discipline- basedCommunity -based/hospital- basedElective / uniformSystematic /apprenticeship (internship)-based

SPICES Model of Educational Strategies 1 Hospital-based SPICES Model of Educational StrategiesStudent centered“What the student learn rather than what is taught"Teacher centeredProblem-basedInformation-orientedSubject or Discipline- basedIntegrated or Inter- professionalIntegration throughout the curriculumCommunity-basedLess emphasis on hospital-based programsHospital -based

SPICES Model of Educational Strategies Hospital- basedSPICES Model of Educational StrategiesElective-drivenAccording to student needs, learning & teaching adjusted to the needs of studentsUniformSystematicTo ensure that all students have had comparable learning experience apprenticeship (internship)-based i.e Opportunistic (=resourceful)

XXXX The rapid rise of and subsequent demand for providers to have expertise in areas such as population health, health policy, healthcare delivery systems, and interdisciplinary care has demanded that medical graduates possess knowledge and skills beyond a thorough understanding of applied anatomy and pathophysiology. This demand for recent graduates to develop a knowledge base beyond traditional medical school content is one major barrier to improving medical education.

Designed to be repetitive yet progressive, the ‘‘integrated curriculum’’ has rapidly risen to popularity with the belief that breaking down the barrier between the basic and clinical sciences improves connections between these disciplines and enhances graduates’ retention of knowledge and development of clinical skills. Many accreditation bodies recently renewed their licensing standards to include the requirement that a curriculum be ‘‘coherent and coordinated’’ and ‘‘integrated within and across the academic periods of study’’.

Step 1 is isolation, in which faculty organize their teaching without considering other subjects or disciplines. Step 2 is awareness, in which teachers of one subject are aware of what is covered elsewhere, but no explicit attempt is made to help students look at a subject in an integrated manner. Step 3 is harmonization, in which teachers communicate with each other about their courses and adapt their content accordingly. Step 4 is nesting, also called infusion, in which teachers target content from other courses within their own courses. Step 5 is temporal co-ordination, in which similar content is covered in parallel across courses. Step 6 is sharing or joint teaching, often conducted when there are common areas of content or there is a need to include new content in a curriculum. Step 7 is correlation, in which an integrated teaching session may be introduced in addition to subject-based teaching. Step 8 is complementary programming, often related to a theme or topic to which several disciplines can contribute. Step 9 is multi-disciplinary, in which themes are identified, sometimes related to an area in which practical decisions need to be made, other times when the subject matter transcends subject boundaries. These themes or problems are viewed through a multidisciplinary lens even though the disciplines maintain their own identity and understanding of the problem. Step 10 is inter-disciplinary, in which there is further development of the commonalities across disciplines. Step 11 is trans-disciplinary, in which the curriculum focuses on the learner’s process of constructing meaning from information and experience. An example cited is the last two years of the Dundee curriculum (Harden et al. 1997), in which students focus their learning around 113 clinical problems or tasks to integrate their experience.

A reas in need of consideration during all phases of integration Ensuring synchronous presentation of material Whether logistical changes lead to active integration of basic sciences and clinical knowledge by students is unclear; simply creating an integrated curriculum does not automatically create cognitive interaction. Similarly, simply coordinating content does not automatically establish integration. We have observed the most common form of published curricular integration in the literature utilizes increased exposure to the clinical learning environment. Rarely but perhaps more clearly referred to as ‘‘integrated clerkships’’, such experiences are shorter and occur earlier in a curriculum than traditional clerkships, typically as part of the basic science years. However, defining such clerkships as ‘‘integrated’’ can and at times has been narrow-sighted. Clerkships occurring during the basic science years without direct correlation to basic science course content do not reflect integration at all. Likewise, multi-disciplinary courses with objectives that are temporally coordinated but delivered as separate lectures by separate lecturers without connections to each other are merely coordinated courses, not integrated. A truly integrated early clerkship would demand that knowledge from the foundational sciences be applied in the clinical environment, and vice versa; creating proximity between two knowledge domains is simply not enough and sits squarely on the lowest rung of Harden’s integration ladder. Integrated courses must be carefully and collaboratively combined to be truly integrated. While thoughtful and precise curricular design is important, emphasis on the individuals delivering the integrated curriculum is an essential detail. Malik & Malik (2011), in a follow-up article to their original report on an integrated curriculum in Malaysia, offer 12 suggestions for a successful, step-wise approach toward total curricular integration. In addition to careful planning, they stress the creation of curriculum development groups with appropriate representation from both the foundational and applied sciences. For instance, a curriculum group for a particular clerkship module should appropriately include a majority of clinicians but must also emphasize participation from basic medical science educators. The authors also highlight the essential need that ‘‘lecturers refer to the contents of other teaching sessions and link and build on what was taught in the other disciplines’’ to ensure that a curriculum is integrated, not merely coordinated. Ideally, integrated sessions would be given synchronously as a collaboration between professors and/or clinicians individually representing the foundational and applied sciences or by a professor from one scientific realm (foundational or applied) with academic knowledge of the other realm. Such a combination of foundational science and applied science education and educators would finally yield the benefits of true integration to students. Additional benefits of trans-disciplinary cooperation among educators could be realized through the establishment of connections between clinicians and basic scientists with the potential to ‘‘produce spin-off effects in teaching and research’’ among professionals that otherwise might not have collaborated (Malik & Malik 2011, p. 99). Preserving the basic sciences The challenges of preparation for post-graduate medical practice demand additional applied learning, particularly with increasing emphasis on the expanding educational requirements for practice including ethics, professionalism, and other social sciences. At the top of the cone are three domains of learning – cognition (knowledge), skills, and attitudes – that are a focus of all levels of the spiral. Additional themes persist throughout all years – clinical methods, ethics, and health promotion – further emphasizing an evolution and subsequent broadening of physician education beyond the scope of this Guide. Integrated curriculum in medical education 3

curriculum’’ and that ‘‘the scientific basis of medicine should be integrated into coursework offered throughout the four years of the undergraduate medical education curriculum’’ (AAMC 2001). The group goes on to explain further challenges in preserving the basic sciences, pointing out that modernizing curricula is shifting the very definition of ‘‘basic science’’. While molecular, biochemical, and cellular mechanisms have been and will continue to be essential foundations for medical practice, adding objectives from scientific fields with increasing clinical relevance such as pharmacology, genomics and proteomics, and behavioral biology is essential to curricular modernization and can only benefit students. The LCME recently reiterated this broader concept of ‘‘basic sciences’’, requiring the inclusion of behavioral and socioeconomic subjects while maintaining biomedical science education to properly support contemporary scientific knowledge (LCME 2013). Bandiera , in tracking curriculum change and shifts in modern medical knowledge, offered revised terminology to reflect broader definitions of ‘‘basic science’’ and ‘‘clinical science’’, suggested their replacement with ‘‘foundational science’’ and ‘‘applied science’’, respectively ( Bandiera et al. 2013). We support a transition to these updated terms to offer further clarity of the definitions within the discussion of integrated curricula. True integration demands there never be an absence of the foundational science component at any stage of the medical school curriculum. Bruner (1960, p. 13) supports this notion, stating, ‘‘A curriculum as it develops should revisit these basic ideas repeatedly, building upon them until the student has grasped the full formal apparatus that goes with them’’. With reports of successful and effective inclusion of the applied sciences in the years typically reserved for the foundational sciences (through ‘‘integrated clerkships’’ or similar), we must not forget that even our most senior students engaged in traditional clerkships should still view these as ‘‘integrated’’ learning opportunities; educators bear a significant responsibility in maintaining and reinforcing the fundamental sciences throughout all stages of the curriculum. Continually revisiting previous topics allows for a progression in which the student begins with a foundation of knowledge and gradually develops the capacity to add increasing levels of complexity and integration throughout the curriculum (Davis & Harden 2003). With so much emphasis on integrating basic science courses or extending clinical experiences earlier into a curriculum, extending basic science content into the clinical years has been a challenge and a major shortcoming of integrated curricula (Schmidt 1998). Examples of foundational science modules integrated successfully into the applied sciences are limited but include electronic modules in the Netherlands (Dubois & Franson 2009) and senior-level capstone courses reviewing and applying basic science in the United States (Spencer et al. 2008). Using unified definitions

educators may apply to evaluate and improve their current or future integrated curricula. Many examples of assessment and evaluation focus on providing students with validated tools allowing them to reflect on the foundational science concepts that led them to clinical decision-making. Reflection is an important skill for lifelong learning in general and for integrating concepts in particular. In describing strategies for integration as a curricular strategy, Goldman and Schroth (2012) suggest that posing specific reflection questions either before or after class sessions can enhance students’ reflective abilities when faculty provide graded feedback and comments for additional reflection. Bierer and others describe an approach that combines multiple-choice questions (Self-Assessment Questions or SAQs) with essay questions (termed Concept Appraisals or CAPPs) that ask learners to provide a narrative interpretation of the mechanisms behind or reasons for the findings in a clinical scenario ( Bierer et al. 2008,2009). Wood and colleagues describe a validation study of a Clinical Reasoning Exercise in which learners are asked to write a single paragraph explaining the mechanisms behind a particular patient problem (Wood et al. 2009); these assignments are then graded by independent raters to assess whether learners’ performance on this exercise correlates with other measures. Williams and Klamen (2012) have described a Diagnostic Justification Exercise used with simulated patient encounters in which learners are asked to develop a differential diagnosis and explain their rationale for including the diseases/ conditions on that differential. Finally, an intervention study comparing students who received probability-based diseaseoriented instruction with students who received conceptually based basic science instruction related to a particular disease showed that students in the basic science group were able to more accurately diagnose cases after a delay than were those in the probability-based group (Woods et al. 2005). The authors suggest that ‘‘... the basic science information, because of its conceptual coherence, was itself more memorable and that it also provided a means to reconstruct the features of individual disease categories after the initial symptom lists had been forgotten’’ (p. 111). Concept maps represent another strategy for assessing integration of knowledge. McGaghie et al. (2000) demonstrated that students’ maps regarding pulmonary physiology concepts became more coherent as a result of participating in an instructional unit on respiratory physiology, and the maps became more similar to maps developed by their instructors. In an earlier study ( McGaghie et al. 1994), however, they showed that maps of experts differ significantly depending on the discipline of the expert (internist, anesthesiologist or physiologist), thus complicating the task of developing a ‘‘gold standard’’ by which to assess students’ maps. In the spirit of integration, perhaps having groups of experts develop concept maps together would be helpful in both identifying important core concepts and in devising ways to assess students’ integration of those concepts. In a study of maps constructed by pediatric residents to represent their understanding of seizures, West et al. (2000) used a hierarchical scoring protocol that assessed concepts, linkages, hierarchies, cross links, and examples to derive an overall score. They demonstrated an increase in overall scores, cross-link scores, and concept link scores following an educational intervention. The Mind Map Assessment Rubric (MMAR), which adds dimensions of pictures and colors to hierarchical scoring of concept maps, has demonstrated interrater reliability in scoring of mind maps constructed by medical students (D’Antoni et al. 2009). In a recent pilot study, Kumar et al. developed pathogenesis maps that were used to test students’ understanding of key concepts. Experts first developed the ‘‘gold standard’’ map, which was then used to generate a list of key terms. Students in the intervention group then used these terms to construct their own maps and received feedback on the accuracy of their maps. Learners in the study group scored higher on quiz items related to content in the maps than had students who had not participated in the mind map intervention (Kumar et al. 2011). In another study, student response to the use of concept maps in Patient-Based Learning (PBL) tutorials (Veronese et al. 2013) indicated that students believed the exercise helped them integrate knowledge about the case and look more carefully at causality and connections among the concepts. Finally, Moni et al. (2005) used feedback from students to refine a scoring rubric that included: the content of the maps (e.g., were relevant concepts included), the logic and understanding demonstrated by the map, and the presentation of the map. While rubrics for grading concept maps are becoming more sophisticated, continued work is needed to further establish the validity and reliability of using them for testing purposes. Karpicke and Blunt (2011) demonstrated that retrieval practice, i.e., studying text, recalling as much as possible on a free recall test, studying again, and recalling again demonstrated better long-term recall on verbatim questions and inference questions than the elaborative strategy of concept mapping. They point out that it is not just memorization, but actively processing the information that has this effect. Longer essays have also been suggested as a means for assessing students’ integration of knowledge from a problembased learning case. For example, Ferguson (2006) describes a method by which individual learners are asked to write a narrative about a case that they have studied in small groups over several weeks. The learner is asked to write, in the form of a conversation with a patient, how the patient’s signs, symptoms and laboratory and imaging results relate to underlying mechanisms of disease, how the treatment recommendations are based on this understanding, and what the patient can expect from the disease and treatment. Writing the narrative in the form of a conversation accomplishes an additional purpose of practicing the skill of explaining difficult concepts in understandable terms. In the University of Iowa (Iowa City, Iowa, USA) Carver College of Medicine’s case-based learning curriculum, learners are required to do written reports of weekly learning issues. A significant component of those reports is the ‘‘application to case’’ section, which gives them practice and reinforcement in integrating information they learn from searching a topic by applying it to a particular patient sce

Progress tests have been used extensively in Europe to assess integration across courses. These tests are given periodically throughout the curriculum, and the items are intended to test cumulative knowledge across courses and vertically across the curriculum. A key component to constructing valid, high quality items for progress tests concerns ensuring their relevance in testing a new graduate’s knowledge. A recent review (Wrigley et al. 2012) describes five criteria for improving relevance: ‘‘... items should test knowledge that is specific to the specialty of medicine, test ready knowledge (knowledge required as a prerequisite to function in a practical situation), be important knowledge which is required for the successful practice of medicine, have a practical relevance for the successful handling of high-prevalence or high-risk medical situations, and the knowledge should form the basis of one or more important concepts of the curriculum’’. Progress tests provide a unique opportunity for assessing growth in students’ knowledge (Williams et al. 2011), and can provide data on which to base decisions about the curriculum as a whole as well as remediation strategies for the individual student. To accomplish these goals, however, requires significant investment of faculty and administrative time to develop item banks and ensure that exams remain relevant. Swanson and Case (1997) provide examples of multiplechoice questions based on patient scenarios that test integration of basic science and clinical knowledge. In addition, they have suggested that open-book exams, especially those that require learners to apply scientific literature, may be especially helpful in assessing higher-order thinking skills such as integration of material. An additional benefit is that such exams drive faculty to write questions that cannot be answered by turning to a page in a book. During clinical education, assessing learners’ ability to apply basic science concepts through their diagnostic reasoning skills often occurs in the context of patient care. Bowen (2006) identifies learner skills in six areas: data acquisition and reporting, problem representation, generation of hypotheses, identifying appropriate diagnoses on the differential, having relevant experience for the case, and general presentation/ organizational skills. She identifies clues that will uncover deficits in each of these areas and offers educational strategies for addressing each of them during clinical education. She further suggests that clinical teachers should ‘‘... encourage reading that promotes conceptualization rather than memorization ....’’ On a related note, ‘‘Learners should be encouraged to identify progressively broader and more complex issues, [and] explore them more deeply’’, thus reinforcing the notion of a spiral curriculum during the clinical years. One strategy for assessing this re-visiting would be incorporating basic science into online clinical cases and writing multiple choice items related to basic science concepts during clerkship examinations. The International Association of Medical Science Educators (IAMSE) and the MedU Consortium, a group of medical educators and students working together to develop innovative strategies and conduct educational research, are currently collaborating on a project called MedU Science to develop virtual patients that focus on causal mechanisms of disease and therapy ( MedU Science 2014). Conclusion Curriculum renewal through integration within and across disciplines is occurring all over the world and has been promoted by many national medical education organizations. Despite and perhaps due to its popularity, the integrated curriculum has lacked significant clarity in the medical education literature and offers significant challenges to its designers. The Carnegie Foundation for the Advancement of Teaching, celebrating 100 years of the influence of the Flexner Report on medical education, accurately and succinctly reported that the difficulty in modernizing a curriculum is ‘‘not defining the appropriate content but rather incorporating it into the curriculum in a manner that emphasizes its importance relative to the traditional biomedical content and then finding and preparing faculty to teach this revised curriculum’’ (Cooke et al. 2006). Selecting content is only part of the battle; successfully integrating it across disciplines and across time to maximize student preparation is the true challenge. Here, we have reviewed theory, models, and examples of integrated curricula, suggested that the spiral curriculum as an ideal model, identified and offered solutions to three frequent shortcomings of integration – ensuring synchronous presentation of material, avoiding the tendency to diminish the importance of the basic sciences, and using unified definitions – and outlined methods of evaluation to objectively track a curriculum’s progress and effectiveness. We hope this guide will assist and encourage critical discussion among educators in all scientific disciplines as they develop, implement, and evaluate modern integrated curricula in medical schools around the world with the goal of equipping learners with the knowledge and skills necessary for the challenges of an exciting and constantly evolving field.

The Integrated Curriculum is becoming an increasingly popular concept internationally. The goal of integration is to break down barriers between the basic and clinical sciences currently in place as a result of traditional curricular structures. Integration should promote retention of knowledge and acquisition of skills through repetitive and progressive development of concepts and their applications. We suggest three areas in need of improvement and clarification for successful integration: ensuring synchronous presentation of material, avoiding the tendency to diminish the importance of the basic sciences, and using unified definitions. Goals and methods to evaluate whether the goals have been met are infrequently reported, utilized, and understood, limiting sustained success and growth of integrated curricula.

2 Integration was one of the key criteria for assessing the degree of innovation in a medical curriculum in the SPICES curriculum model (Harden, 1984). Why????

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