Integrating Basic Science Without Integrating Basic Scientists: Reconsidering the Place of Individual Teachers in Curriculum Reform Robin Hopkins, PhD, Daniel Pratt, PhD, Judith L. Bowen, MD, and Glenn Regehr, PhD
Abstract The call for integration of the basic and clinical sciences plays prominently in recent conversations about curricular change in medical education; however, history shows that, like other concepts related to curricular reform, integration has been continually revisited, leading to incremental change but no meaningful transformation. To redress this cycle of “change without difference,” the medical education community must reexamine the approach that dominates medical education reform efforts and explore alternative perspectives that may help to resolve the cyclical
“problem” of recommending but not effecting integration. To provide a different perspective on implementing integration, the authors of this Perspective look to the domain of educational change as an approach to examining the transitions that occur within complex and evolving environments. This area of literature both acknowledges the multiple levels involved in change and emphasizes the need not only to address systemic structure but also to prioritize individuals during times of transition. The struggle to implement curricular integration
in medical education may stem from the fact that reform efforts appear to focus largely on transformation at the level of curricular structure as opposed to considering what learning needs to occur at each level of change and highlighting the individual as the educational change literature suggests. To bring appropriate attention to the place of individual educators, especially basic scientists, the medical education community should explore how the mandate to integrate clinically relevant material may impact these faculty and the teaching of their domains.
Editor’s Note: Commentaries by A. Haramati and by M. Salmon, D. Williams, and K. Rhee appear on, respectively, pages 133–135 and 136–138.
of theoretical and practical knowledge as problematic because they believe that, firstly, this separation weakens the transfer of knowledge to the practical context, and secondly, that students are often unmotivated to learn large amounts of detailed information that seems disconnected from the practical setting.2–7
bring together foundational knowledge and clinical practice, for the most part, the implementation of integration has remained a challenge.12
edical education is in a state of transition. National recommendations are being published, curricula are being revised—and schools and educators are responding. A major challenge often addressed in this wave of reform is the historical segregation of foundational knowledge and clinical practice. The predominant curricular model of the past 100 years has been one in which students spend 2 years in the university setting learning the medical, or “basic” sciences, and then 2 years in teaching hospitals learning at the bedside of patients. Originally described by Flexner,1 this segregated structure has withstood over a century of curricular reform; however, many contemporary medical educators now perceive this separation Please see the end of this article for information about the authors. Correspondence should be addressed to Dr. Hopkins, Department of Human Physiology, 122 Esslinger Hall, 1240 University of Oregon, Eugene, OR 97403; telephone: (541) 525-4915; e-mail: [email protected]
Acad Med. 2015;90:149–153. First published online August 19, 2014 doi: 10.1097/ACM.0000000000000437
Academic Medicine, Vol. 90, No. 2 / February 2015
The commonly espoused solution to this segregation is curricular “integration.”8 The concept of integration is conceptualized and used differently across the medical education literature.9 The type of integration we refer to in this Perspective is the bringing together of clinical science, the practical application of medical knowledge, and basic science, the subject areas contributing to fundamental medical knowledge. In medical education, the promise of integrating basic and clinical science is that doing so will increase students’ retention of knowledge, improve the transfer of knowledge to the clinical setting, and sharpen students’ interest by allowing them to see the relevance of basic science content to clinical practice.10,11 The concept of integration is not new. Manifested in different curricular structures, integration has been a recurring theme throughout the history of medical education reform. Despite being reiterated in recommendations for change and despite continued efforts to
To move toward actually implementing curricular integration, therefore, a relevant question to ask is, Why does this perpetual discussion of the same theme continue with little substantial change in the training of physicians? To help address this question, we look to the broader field of educational change to explore new ways of thinking about the integration of clinical and basic sciences in, specifically, medical education. First, we trace the history of curricular integration in U.S. and Canadian medical education. This brief history is followed by a reflection on how themes of curricular reform have tended to resurface over the past century. Finally, we discuss the literature of educational change in light of how it may inform the conversation about change in medical education, particularly the implementation of integration. Integration: Then and (Still) Now
The field of medical education has been working toward curricular integration for over 60 years. Case Western Reserve University School of Medicine is recog nized as implementing the first integrated
curriculum in the early 1950s, as lectures began to incorporate clinical examples or include presentations from visiting physicians.13 Later, McMaster University moved toward integration with the intro duction of problem-based learning in 1969. One of the expressed objectives of this innovative curriculum was to inte grate the basic and clinical sciences in the context of clinical problems.14 Similarly, in the early 1990s, the University of Calgary Faculty of Medicine introduced a curriculum through which relevant basic and clinical science material were to be learned in the context of “clinical presentations”—that is, the different ways patients present to physicians, such as with a headache, abdominal pain, or fever.13 Thus, in the context of different schools and in the form of different curricular structures, integration was a recurrent theme of reform throughout the second half of the 20th century.15 Yet, today, curricular integration is not fully actualized and continues to appear as a central recommendation in reports for curricular reform. The Future of Medical Education in Canada: A Collective Vision (the FMEC report) acknowledges the integration and timing of the basic and clinical sciences as one of the priority areas to be addressed in the training of physicians in Canada.16,17 Specifically, the report recommends that “both human and biological sciences must be learned in relevant and immediate clinical con texts throughout the MD education experience”16(p20) and that the basic and clinical sciences “must be increasingly integrated so that students think about clinical applications as they learn basic sciences and about scientific principles as they learn clinical skills.”16(p20) Simi larly, Educating Physicians: A Call for Reform of Medical School and Residency recommends integration of formal knowl edge and clinical experience.8 A com mission on medical education sponsored by the Robert Wood Johnson Foundation recommends that “medical schools should ensure that the sciences of medical practice be integrated throughout the entire course of study.”18(p413) Other experts in the field of medical education, including a former editor of this journal, have echoed this recommendation.19 Thus, over 60 years after Case Western’s first effort at bringing the basic and clinical sciences together, educationalists are still espousing and working toward
the same goal: integration. It seems appropriate therefore, that Boudreau and Cassell have posed the question, “why [has]…the urge to seek integration been so persuasive, and the solutions so intrac table?”12(p382) The Curricular “Carousel” of Medical Education
Curricular integration, of course, is not the only medical education reform effort to experience this recurring and ongoing discussion. Sociologist Bloom20 was one of the first to note that despite medical educators’ frequent implementation of curricular reforms, the teaching and learning experience of medical students has remained remarkably similar. After reviewing major reports of reform throughout the past century, Christakis21(p706) came to a similar conclusion, writing, “Typically these reports identify strikingly similar problems with medical education, claim that previous reports have gone relatively unheeded, argue that reform is essential and urgent, and prescribe corrections that are also strikingly similar.” Similarly, in analyzing the language medical educators use to describe these recurring calls for change, Whitehead and colleagues22 use the apt metaphor of a carousel: The returning themes of curricular reform in medical education are like ponies coming around and around, again and again. The literature does acknowledge that modifications and adjustments have been occurring constantly in medical education to keep training current with the advancements of medical science and technology, but describes these changes as being superficial, leaving the basic and clinical sciences still largely segregated.20,22–24 The consensus appears to be that although changes have occurred, they remain at the level of curricular tinkering25 rather than producing fundamental change. Skochelak26 affirms the medical education community’s tendency to tinker in her review of reports calling for change in medical education over the past decade. Her findings also show that the same themes are discussed repeatedly with no more than incremental change over the past 10 years. Her recommendation, which has been echoed by others in the medical education community,27 is
that medical educators have thoroughly identified and contemplated the problems facing their field. She states that “we can be assured that we don’t need to keep asking, ‘what should we do?’ but rather ‘how can we get there?’”26(pS32) We would suggest, however, that to answer the question of how to get there, medical educators must first ask why change has been so hard. To address this question, and in the hope of informing the perennial quest to more effectively integrate the basic and clinical sciences in medical curricula, we now look to a domain that focuses on large-scale transitions: the field of educational change. Gaining insight through its literature into how this field approaches change may help the academic medicine community to get off the “carousel” of curricular integration. Educational Change—Broadly and in Academic Medicine
Educational change is a broad term referring to reform efforts in education. The context of educational change is similar to that of medical education in that there is ongoing concern regarding the limited impact of reform efforts, despite the large amount of resources devoted to these endeavors.28,29 Commonly referred to as the “paradox of change without difference,”30 this phenomenon, describing the minimal impact of educational reform efforts, largely echoes the recurrence of the same recommendations that plague medical education. The educational change literature highlights the importance of the different levels of the system in undertaking reform. “Levels” include a teacher in his or her classroom, the school he or she works in, the school district, and local and federal governments.31 In medical education, one level of change involves individual educators: the basic scientist teaching in a virtual or actual classroom or the clinical instructor guiding learning in a clinic or on the wards. Each of these individuals is a member of a department or faculty, which is then embedded within the larger medical school. The medical school is most often housed within a university and associated with teaching hospitals. These institutions, in turn, are under the authority of provincial or state educational and health care systems. Michael Fullan,31 one of the
Academic Medicine, Vol. 90, No. 2 / February 2015
leading scholars in educational change, points out that when these various levels of change are working at cross-purposes, change is likely to fail. Fullan notes that “a teacher cannot sustain change if he or she is working in a negative school culture; similarly, a school can initiate and implement successful change, but cannot sustain it if it is operating in a less than helpful district; a district cannot keep going if it works in a state that is not helping to sustain reform.”31(p18) While advancing the idea that interrelated levels of change must be addressed for successful reform, the educational change literature draws particular attention to one of those levels: individual teachers. One of the most established notions in this area is the importance of focusing on the teachers themselves. In her review of educational reform, Woodbury32 found substantial evidence that the thinking and practice of individual teachers centrally impacts educational change. Researchers in educational change largely agree that any attempt to significantly change curricula must start with teachers33 and continue to hold them at the center.34 By contrast, the literature regarding the implementation of integration in medical education tends to focus on the level of curricular structure. To illustrate, Irby and Wilkerson35 identify integrated curricular structures as one of five environ mental trends in academic medicine. Medical educators reporting the experi ence of implementing integration at their schools often provide descriptions of curricular design features along with figures illustrating the organization of different courses, various blocks, and their relationships to one another.4,10 They explain how their curriculum was developed and how various content areas and themes are organized. For example, in describing the efforts of eight schools implementing integration, Schmidt36 uses the language of architects, mentioning the “structure” of new integrated courses and “blueprints” for new curricula. Amidst the overlying conversation regarding various integrated structures, the voices of individual educators— particularly those of basic scientists— appear to be lost. When stakeholders are addressed in these descriptions, they mostly include groups who have already bought into change, such as the leaders of educational reform, students who
Academic Medicine, Vol. 90, No. 2 / February 2015
are taking an active role in curricular change activities, and directors of newly integrated courses.11 In other studies, faculty members whose perspectives have been gathered regarding integration are all from the clinical specialties rather than the basic sciences,37 or the perspectives reported represent only those of highlevel officials within the administration.38 When basic scientists have been included, their views are reflected only through their answers to a few Likert-type questions on a questionnaire that was also administered to clinicians.39 Despite the seemingly muted voice of basic scientists in the literature, one challenge of implementing curricular integration often mentioned is resistance from these faculty. In general, basic scientists are reported as having a negative attitude toward change. Different schools’ accounts of implementing integration highlight the unwillingness of basic science faculty to adapt to a new curriculum.2,11,36 Some report that basic scientists perceive integration to be unidirectional40 and that they are uncomfortable trying to put their teaching into clinical contexts because of their lack of clinical knowledge.6 When forced to integrate, basic science departments are noted as displaying “anxiety, antipathy, lack of cooperation, and general mistrust.”41(p15) Thus, in the ongoing conversations about integration, there seems to be a disconnect between how we in the academic medicine community talk about change and the challenges we are having in implementing it. While the focus of the literature appears to be on the organization and structural level of the curriculum, the in-the-trenches struggles do not appear to be related to curricular design but, rather, to factors associated with the level of individual educators, mainly their perceived resistance to change. In addition, although being labeled as resistant to reform, the perspectives of basic scientists and their experiences of change are largely missing from the literature. The educational change literature, therefore, brings an illuminating perspective to the “carousel” of efforts in medical education to integrate curricula. Although this area of scholarship emphasizes the need to address multiple levels during times of change, including individual educators as well as systemic
structures, it highlights the importance of individual teachers as key to the change process. As summarized by Fullan,31 “educational change depends on what teachers do and think—it’s as simple and complex as that.” Implications for Medical Education Research and Practice
The medical education community seems to address Skochelak’s26 challenge—“how can we get there” (how do we effect curricular integration)—by focusing on the organizational structure of the curriculum, even though the challenges more often concern the struggles of individual educators facing change. Therefore, moving forward, as the community addresses the challenge of curricular integration, it will likely have to attend not only to curricular structures but also more fully to the individuals involved in the change, particularly the basic scientists who will be directly involved in enacting the new curriculum. To this end, as Fullan31 suggests, medical educators might conduct research on better understanding the experiences of basic scientists who are at different points along the process of reform. What is the experience like for those who have undergone, are undergoing, or anticipate such a change? How do they understand the teaching of basic science within this new mandate of “clinical relevance”? What learning must occur in order for them to get there? What do they feel they have to give up in this process? Do they perceive any benefits, and if so, what are they? Understanding what integration means for individual basic scientists at varying stages of change will allow the academic medicine community to better anticipate and address tensions arising in future attempts of reform. This understanding will also inform the structural systemic changes needed to support individuals undergoing these transitions and, in turn, allow those in volved in reform to make more informed decisions throughout the process. Summary
Current reforms in medical education reiterate many of the same challenges the field has been voicing for over half a century: the divided structure of the medical curriculum, the perceived lack of relevance of basic science material
as currently delivered, and the lack of students’ retention and application of this material in clinical practice. The current approach to addressing these concerns is also nothing new; integrating basic science and clinical knowledge remains a central recommendation in the most recent calls for reform and in many papers in the medical education literature. Several authors have suggested that the community must move beyond the question of what is needed to the question of how best to get there. However, we would argue that the key to this challenge lies in the question, Why, after years of reiterating the need for and working toward the goal of integration, are we as a medical education community still trying to find traction on implementing change? The educational change literature speaks to the importance of attending to the multiple levels of change, but in particular to the individual teachers who will be the ones actually implementing the change. Given the complexity and collaborative nature of educational reform, we suggest delving beneath the models of curricular structure that dominate current conver sations, and developing an understanding of what those curricular changes mean to those who are asked to live them and carry them out. Focusing not only on what we are integrating but also on who we are integrating may be the key to moving beyond change without difference, and enacting change that is both successful and meaningful. Funding/Support: During the development of this paper, Robin Hopkins was supported by a doctoral salary award from the Social Sciences and Humanities Research Council of Canada. Other disclosures: None reported. Ethical approval: Reported as not applicable. Previous presentations: Robin Hopkins presented an earlier version of this review, “Curricular integration: Not what we are bringing together, but who,” at the American Association of Anatomy’s Annual Meeting at Experimental Biology, San Diego, California, April 2012. Dr. Hopkins is instructor, Department of Human Physiology, College of Arts and Sciences, University of Oregon, Eugene, Oregon. Dr. Pratt is professor of educational studies, Faculty of Education, and senior scholar, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada. Dr. Bowen is professor, Department of Medicine, Oregon Health and Science University, Portland, Oregon. Dr. Regehr is professor, Department of Surgery, and associate director, Centre for Health Education Scholarship, University of British Columbia, Vancouver, British Columbia, Canada.
References 1 Flexner A. Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4. Boston, Mass: Updyke; 1910. 2 Bowe CM, Voss J, Thomas Aretz H. Case method teaching: An effective approach to integrate the basic and clinical sciences in the preclinical medical curriculum. Med Teach. 2009;31:834–841. 3 Spencer AL, Brosenitsch T, Levine AS, Kanter SL. Back to the basic sciences: An innovative approach to teaching senior medical students how best to integrate basic science and clinical medicine. Acad Med. 2008;83:662–669. 4 Wilkerson L, Stevens CM, Krasne S. No content without context: Integrating basic, clinical, and social sciences in a pre-clerkship curriculum. Med Teach. 2009;31:812–821. 5 Grande JP. Training of physicians for the twenty-first century: Role of the basic sciences. Med Teach. 2009;31:802–806. 6 Pawlina W. Basic sciences in medical education: Why? How? When? Where? Med Teach. 2009;31:787–789. 7 Smith K. The case for basic sciences in undergraduate education. Clin Teach. 2010;7:211–214. 8 Cook M, Irby DM, O’Brien BC. Educating Physicians: A Call for Refrom of Medical School and Residency. San Francisco, Calif: Jossey-Bass; 2010. 9 Martimianakis MA, Whitehead C, Webster F, Mylopoulos M. The many faces of “integration” in medical education: A discourse analysis. Paper presented at: Canadian Conference on Medical Education; April 16, 2012; Banff, Alberta, Canada. 10 Dahle LO, Brynhildsen J, Behrbohm Fallsberg M, Rundquist I, Hammar M. Pros and cons of vertical integration between clinical medicine and basic science within a problembased undergraduate medical curriculum: Examples and experiences from Linköping, Sweden. Med Teach. 2002;24:280–285. 11 Muller JH, Jain S, Loeser H, Irby DM. Lessons learned about integrating a medical school curriculum: Perceptions of students, faculty and curriculum leaders. Med Educ. 2008;42:778–785. 12 Boudreau JD, Cassell EJ. Abraham Flexner’s “mooted question” and the story of integration. Acad Med. 2010;85:378–383. 13 Papa FJ, Harasym PH. Medical curriculum reform in North America, 1765 to the present: A cognitive science perspective. Acad Med. 1999;74:154–164. 14 Neville AJ, Norman GR. PBL in the undergraduate MD program at McMaster University: Three iterations in three decades. Acad Med. 2007;82:370–374. 15 Enarson C, Burg FD. An overview of reform initiatives in medical education. JAMA. 1992;268:1141–1143. 16 Association of Faculties of Medicine of Canada. The Future of Medical Education in Canada (FMEC): A Collective Vision for MD Education. 2010. http://www.afmc.ca/ future-of-medical-education-in-canada/ medical-doctor-project/pdf/collective_vision. pdf. Accessed June 19, 2014. 17 Hodges BD, Albert M, Arweiler D, et al. The future of medical education: A Canadian environmental scan. Med Educ. 2011;45:95–106.
18 Marston R, Jons R, eds; Commission on Medical Education: The Sciences of Medical Practice. Medical Education in Transition. Princeton, NJ: Robert Wood Johnson Foundation; 1992. 19 Whitcomb ME. The teaching of basic sciences in medical schools. Acad Med. 2006;81:413–414. 20 Bloom SW. Structure and ideology in medical education: An analysis of resistance to change. J Health Soc Behav. 1988;29: 294–306. 21 Christakis NA. The similarity and frequency of proposals to reform US medical education. JAMA. 1995;274:706. 22 Whitehead CR, Hodges BD, Austin Z. Captive on a carousel: Discourses of “new” in medical education 1910–2010. Adv Health Sci Educ Theory Pract. 2013;18: 755–768. 23 Weatherall DJ. Science in the undergraduate curriculum during the 20th century. Med Educ. 2006;40:195–201. 24 Finnerty EP, Chauvin S, Bonaminio G, Andrews M, Carroll RG, Pangaro LN. Flexner revisited: The role and value of the basic sciences in medical education. Acad Med. 2010;85:349–355. 25 Ludmerer KM. Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care. New York, NY: Oxford University Press; 1999. 26 Skochelak SE. A decade of reports calling for change in medical education: What do they say? Acad Med. 2010;85:S26–S33. 27 Raszka WV Jr, Bannister SL. Celebrating birthdays: An update on the status of undergraduate medical education. Pediatrics. 2011;127:807–809. 28 Gess-Newsome J, Southerland SA, Johnston A, Woodbury S. Educational reform, personal practical theories, and dissatisfaction: The anatomy of change in college science teaching. Am Educ Res J. 2003;40:731–767. 29 Southerland SA, Sowell S, Enderle P. Science teachers’ pedagogical discontentment: Its sources and potential for change. J Sci Teacher Educ. 2011;22:437–457. 30 Woodbury S, Gess-Newsome J. Overcoming the paradox of change without difference: A model of change in the arena of fundamental school reform. Educ Policy (Los Altos Calif). 2002;16:763–782. 31 Fullan M. The New Meaning of Educational Change. 4th ed. London, UK: Teachers College Press; 2007. 32 Woodbury S. The Reform of Practice and the Practice of Reforms: Teachers and Change in High School Mathematics. Salt Lake City, Utah: University of Utah; 2000. 33 Bailey B. The impact of mandated change on teachers. In: Bascia N, Hargreaves A, eds. The Sharp Edge of Educational Change: Teaching, Leading, and the Realities. London, UK: Falmer Press; 2000. 34 Southerland S, Sowell S, Blanchard M, Granger E. Exploring the construct of pedagogical discontentment: A tool to understand science teachers’ openness to reform. Res Sci Educ. 2011;41:299–317. 35 Irby DM, Wilkerson L. Educational innovations in academic medicine and environmental trends. J Gen Intern Med. 2003;18:370–376.
Academic Medicine, Vol. 90, No. 2 / February 2015
Perspective 36 Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Acad Med. 1998;73(9 suppl):S24–S31. 37 Tresolini CP, Shugars DA. An integrated health care model in medical education: Interviews with faculty and administrators. Acad Med. 1994;69:231–236.
38 Anderson MB, Kanter SL. Medical education in the United States and Canada, 2010. Acad Med. 2010;85(9 suppl):S2–S18. 39 Brynhildsen J, Dahle LO, Behrbohm Fallsberg M, Rundquist I, Hammar M. Attitudes among students and teachers on vertical integration between clinical medicine and basic science within a problem-based
undergraduate medical curriculum. Med Teach. 2002;24:286–288. 40 McCrorie P. The place of basic sciences in medical curricula. Med Educ. 2000;34: 594–595. 41 Sweeney G. The challenge for basic science education in problem-based medical curricula. Clin Invest Med. 1999;22:15–22.
Cover Art Artist’s Statement: What’s on Your Mind? I created this piece as a premedical student when I had the wonderful opportunity to take a photography class that included work in the darkroom. Our instructor had us begin by making photograms, which create photographic images without a camera by shining light straight from an empty enlarger onto various objects placed on top of photographic paper. During the exercise, I realized the concept was the same as a radiograph: Light that made it to the paper would turn the paper dark, whereas areas of the paper unexposed to light due to obstructing objects would remain white. I was thrilled by the idea of using an actual radiograph over the photo paper to create a playful inversion of the familiar black and white shapes; light would shine through the white parts of the radiograph onto the photo paper beneath it, and thus bone would appear black. I asked a friend who worked in the radiology department at a local hospital for some deidentified radiographs. Since computer technology is now the mainstay of medical imaging, he had to rummage to find them, but I was delighted when he cleverly offered a radiograph of a skull to this student of neurobiology.
Academic Medicine, Vol. 90, No. 2 / February 2015
the orbit and into the skull through the cervical spine for visual effect.
What’s on Your Mind?
Once I had the radiographs in hand, I remembered an almost diabolical-looking series of photos of my father, taken when I was in high school, for which he gamely moved a flashlight around his head while I snapped pictures. For the photogram, I cut up the negatives from the photos of my father and splayed them over the skull radiograph, hoping to convey a sense of identity crisis within whatever thorny experience of illness led this imagined patient to the x-ray machine. I took my favorite glass and an Excalibur-shaped letter opener from my grandfather and placed them on the photo paper over
Although the foreboding faces in this piece do not necessarily capture a universal experience of medical care, I do think they reflect the experiences of some of my patients. When thrust into the hospital’s lair, their journey of illness all too often plays out alongside and separate from their medical team’s detective work. In our role as health care providers, we may unravel the story of the diagnosis through imaging, labs, and sophisticated procedures, but these plot changers do not always shed light on the lived experience of being ill, the psyche of suffering, and the disembodiment of being combed for clues, whether by relentless human touch or the piercing gaze of a radiograph. My hope is that this artwork inspires a thoughtful consideration of the merits of bridging the gap between the medical and humanistic aspects of caring for patients. Acknowledgments: The author would like to thank Ryan Mayock for his help with this artwork. Deva M. Wells Ms. Wells is a fourth-year medical student, University of Washington School of Medicine, Seattle, Washington; e-mail: [email protected]