Integrated teaching in medicine – Indian scene

Abstract

As the name implies ‘integration’ involves several subjects, where importance of individual subjects is subordinated to the main goal of training a functional physician. The importance of individual subjects in medicine may differ widely among various stakeholders for various reasons. However, importance of individual subjects can be developed independently by other means. Lectures are traditional method of teaching in medical subjects but learning may not be synchronous with them. The pyramid of average learning retention rates are lectures 5%, reading 10%, audio-visual 20%, demonstration 30%, group discussion 50%, practice by doing 75%, and teaching others 90%. Lectures are criticized as ‘spoon feeding’ and being overloaded with information that may not be relevant. Tutorials, expected to supplement learning in small groups help only if the students come prepared with prior study. In the West, attempts to stimulate student interest in medical subjects, particularly basic sciences have resulted into two suggestions, (a) early exposure to patients to create an awareness of the final objective of their study and (b) the use of integrated teaching. An integrated teaching offers several advantages. Basic sciences are simplified without needless details and taught along with clinical disciplines. Learning is abbreviated without repetition in different subjects giving a composite picture with simultaneous clinical demonstration. At present, integration is done only in the students’ mind at widely dispersed dates and is not effective. This concept may not be relished by the teachers of both basic and clinical sciences who may feel their interests to be in jeopardy. Integration involves all subjects and therefore should be an official policy applicable to institution as a whole and cannot be implemented by individual subjects. It requires freedom for each institution or university to adapt its own methods at different levels in consultation with faculty. Medical education in the United States today is standardized after progressive efforts. Rapid changes are possible in USA, which may take very long in other countries, because of several reasons (they admit graduates, each medical school has freedom of planning, assessment is mostly internal, final and strict and national agencies check the standards). Additionally, it is realized that a well designed curriculum and good teaching methods will help student gain a body of knowledge, habits of study and capacity for independent thinking, which will enable him to continue his education even after he leaves the medical school. To stimulate student interest, basic sciences are pruned to meet the requirements for a basic doctor, course of study is reduced and internship is increased to give more of in-service training. Physiology and Biochemistry are taught only during the first year in a period of nearly 6–8 months and a General Pharmacology course for 3–6 months. Systemic Pharmacology is integrated with other clinical courses. There is actually a virtual check on the standards of each graduate applicable to both the local as well as foreign medical graduates. In UK, following a Royal Commission report, Universities introduced the “systems-based teaching” in place of “subject-based teaching”, for example, a “heart” module would include anatomy and physiology of the heart, clinical examination, clinical cardiology and cardiothoracic surgery in one module. Exposure to clinical sciences begins at the second year itself. Lectures are reduced and a greater emphasis is placed on making the student study, understand, and learn for himself. After a policy announcement in ‘Tomorrow's Doctors’ by General Medical Council, in 2003, integration of clinical and nonclinical subjects has gained further momentum. Two broad methods have generally been adopted, lecture-based learning (LBL) and problem-based learning (PBL), each varying widely. A LBL requires fewer staff members to deliver lectures and students listen to leading clinicians or academics. However, students are made to absorb the information passively without interaction. They may also be overloaded with irrelevant information. In contrast, a PBL is acquired by solving clinical problems and learning basic information in the same context in which it will be used. The student assumes primary responsibility supported by student–faculty interaction. The course is patient orientated from day one and students are heavily involved in clinical setting from the very first year. Teaching consists of tutor-led small groups with computer work, practical sessions, and large amount of time for personal study. It employs two fundamental principles, learning basic sciences in the process of analyzing typical cases and learning motivated by curiosity. As per information gathered from graduates of Liverpool University, students are divided into small groups of 10 and monitored by a tutor/facilitator. In the first year, study is kick started with a ‘clinical problem’ or a ‘case study’. The students study for themselves from books, library, etc., to acquire the background information in basic sciences of anatomy, physiology, biochemistry relevant to this case. At the end of the week they pool up their information, involve in group discussion under the guidance of a facilitator. With a fresh problem every fortnight, they are programmed to build up their knowledge by self-study. They also have sessions on ethics, communication skills, history taking, and attend one lecture each day on different subjects. They have practical sessions for learning normal parameters (recording blood pressure, etc.). They do not have dissections or animal experiments. They never visit a basic sciences department nor look into a microscope or perform a laboratory exercise. In the following 4 years, they are attached to clinical consultants with increasing level of disease comprehension-history taking, diagnosis, treatment, and follow up. Even during this period process of self-learning continues. There is a yearly assessment and expulsion occurs on failure more than twice. The degrees are recognized by General Medical Council (GMC) and employment provided in National Health Service (NHS). Many go on to acquire a postgraduate qualification of Royal Societies. Older universities like Cambridge adopt a different pattern. For example, during initial 2 years, integration in the basic sciences has new compositions like functional architecture of the body, homeostasis, molecules in medical sciences, biology of disease, mechanisms of drug action, neurobiology and human behavior, and human reproduction, etc. Clinical studies are assisted with small-group ‘clinical supervisions’ by junior doctors and they consist of basic clinical methods (history-taking, physical examination, differential diagnosis, ordering and interpretation of basic investigations), the life course (pediatrics, women's health, cardio-thoracic medicine, oncology, aging and degenerative diseases, and psychiatry linked by a record of longitudinal patient attachments collected in a portfolio, experience in primary and community care) and acquisition of knowledge, skills, and attitudes to practice independently (through attachments in general practice, medicine, surgery, emergency medicine, acute care, etc). At the end, the students are awarded the degree of MB, BChir with provisional registration. For full registration, one needs to complete a 2-year period to demonstrate fitness to practice medicine. In India, the medical education is a legacy from UK. Before 1900, there were only three medical colleges, at Madras, Calcutta, and Bombay. Today there are 335 recognized medical colleges (2011) with 40525 undergraduate seats. UK has reviewed its medical education with a Royal Commission in 1965–68 and revised it vigorously from the 1990s with varying patterns. We are, however, reluctant to revise and adopt the newly established objectives. Medical education is centralized with Medical Council of India (MCI). It does not consult or involve the students or staff of the medical colleges at the periphery who are affected by its policies. On the plea of producing more doctors for rural areas, MCI is permitting more medical colleges to be started in private sector and increase in the number of admissions. However , MCI does not cross-check the individual graduates before registration. There is no expulsion of students with repeated failures and every medical student becomes a doctor irrespective of the years spent in the college or the skills learnt. Universities have no role in medical education except to conduct the examination and award degrees. Teachers deliver lectures and concentrate only on their subject. The students study before examination with an aim to pass and qualify. Although external examiners are there, standards vary from day to day and center to center. Admissions are made on the basis of region, caste, and gender and the rules differ from state to state and Government to private colleges. Common Entrance Test for all states is on the anvil but has limitations with medium of instruction in regional languages up to 12th standard in several states. Standards are determined by the buildings, rural or urban location, and age of the institution. But the quality of students, teachers, and the teaching methods always fluctuate. The objectives and pattern of medical education are progressively changing world over with greater scientific advances, improvement in standards of premedical education, etc. There are greater expectations from students, increased demand from patients and public for quality medical care. Medical education has become expensive too. The present syllabus of the 12th class is advanced with latest information in physical and biological sciences and mathematics. Students who eagerly join with this background lose interest with basic medical sciences, which fail to ignite their interest with no contact with patients. It can be remedied with integrated system of teaching. Integration cannot be done by individual subjects but it needs an official doctrine and not a personal obligation. It is also premature to attempt PBL in India, which requires radical changes in administrative and faculty attitudes, not easy to enact. In PBL, faculty becomes more exposed to students, departments relinquish some curricular authority, and curriculum assumes a more important status. Occasional reports have been published on successful trial of integrated teaching in India based upon the feedback received from the students.[1,2] MCI has also recognized the need for integration in its ‘Revised Regulations for Graduate Medical Education 2012’ spelling laudable objectives for individual subjects. However, it still retains the old mandatory outline of number of lecturers, tutorials and practicals, examination papers, the marks, examiners, etc. The areas like internal assessment, attendance, and removal from college are likely to be opposed by student bodies. Although, a National Eligibility-cum-Entrance Test for Medical Postgraduate Courses, ‘NEET’, is to be held, there is no mention of a licensing examination before registration. Mere statements by MCI that ‘horizontal and vertical integration are to be attempted’ cannot achieve integration. Early clinical exposure is possible only with official policy. Integrated teaching can succeed only through an official institutional policy and not optionally by individual departments. Naturally it can vary from institution to institution depending on the facilities. Each college should have a cell for drafting, discussing, and developing the curriculum by Departments brought out of their isolated interests. There is a need for a national organization to develop and demonstrate such teaching methods. Teaching methods can be monitored only by a national level examination. Only MCI can maintain standards by instituting such examinations, which verify if its objectives are being followed. Several suggestions can be made. To begin with, MCI should give only a broad outline of the duration of course, distribution of subjects into basic and clinical sciences. Details about method of teaching should be left to Universities and the medical colleges. Only major changes need be referred to MCI. Integrated teaching should be officially accepted as a policy. Each college should have an Academic Dean, assisted by a committee of teachers including students to formulate the integration at institutional level. The whole faculty should meet once a year to review the experiences of previous year and reform the local methods immediately. An independent examination body should be developed at national level with trained staff. It should prepare the question banks and continuously update them. No individual medical college should be entrusted with this work and this should be handled by a whole time organization. This is a key step to ensure the standards. Students’ responsibility in learning has to be increased by expulsion on second failure at any stage. To check the standards of each graduate there should be a nationwide examination at preclinical, clinical levels and a final examination after resident training. At the National level there should be an association of medical colleges that meets once a year for 5 days and deliberates separately the experiences in teaching basic and clinical sciences and hospital management, etc. The suggestions emerging can be passed on to the Government of India and MCI.