Integrated: focus on the staff as much as the curriculum.

by reestheskin on 16/09/2014

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My undergraduate course in Newcastle starting in 1976 was said to be ‘integrated’. At the time I am not certain I knew what the alternative was, but soon cottoned on. The idea was that we wouldn’t have a series of lectures on anatomy, the physiology, then pharmacology etc. Rather some higher order topic (e.g. the CVS) would be covered by staff with different areas of expertise. I assumed that no single member of staff had the necessary expertise across the board. There are pros and cons to this approach. I quite like the idea of a single individual setting out how they will cover a topic, as you have time to get used to lecturing style and so on; and it is perhaps easier to read ahead, if one person is in control. On the other hand, for many if not most topics, the traditional or historical disciplines don’t make sense. In the clinical area, physicians carry out procedures and surgeons don’t just don’t operate (although many of them would like to).

There are however challenges to having an integrated course. One example I remember, was listening to a lecture on some type of cancer and the surgeon explaining the basis of the classification used. The next lecturer, a pathologist, led with an opening statement about how the classification method described by the surgeon just a few minutes earlier, was wrong. Of course the surgeon had left by this time. Nobody it seemed to me knew what anybody else was talking about with any fine sense of granularity. I learned that the course may be said to be integrated, but the staff were not, and if the staff are not, then it isn’t really integrated at all. What seemed to happen was that everybody came on, presented their monologue, and then dispersed back to their silo. I doubt if the ‘course’ actually ever existed except as a timetable arranged by a course organiser with one hour time-slots: ‘surgical bit’, ‘pathology bit’; ‘physician bit’, ‘ethics bit’ etc.

I was thinking about this because of a mistake I made recently. I had just diagnosed a case of cutaneous endometriosis, and the history of cyclical pain, bleeding and swelling of the skin lesion, is quite unforgettable. It is of course very rare, and not the sort of thing we expect students to know about. But if the patient is in front of you, it makes (I thought) a memorable learning moment. So, I introduced the patient to a group of students, and I was aware at least at a subconscious level that they didn’t seem so enthralled at the diagnosis as me. I registered some degree of puzzlement, but thought nothing of it until I was chatting to one the students later in the day. The students were year 4 students, the year in which they are exposed to O+G— this I knew. But what I had forgotten, was that this was the first carousel of the year: none of these students would have done O+G, and therefore I couldn’t have expected them to know about endometriosis. That is why they looked puzzled.

The lesson for me here is that one giant challenge for undergraduate medicine is that the teachers need to be ‘integrated’. But we are not. Most of us live in professional silos. A danger is that you end up with lots of excel spreadsheets mapping out all the ‘competencies’ that you claim students need. This is a complex process, and one that I think exists in documents but not in the real world. Just as a physics teacher needs to know whether a student can understand calculus, a proper clinical teacher needs to know all the things students have been exposed to. This means that all staff need to know what students learn in many other disciplines (e.g. ethics, statistics) so that any clinical exposure can build on this knowledge. We don’t need another statistics slot (to give an example) but we do need all the staff to already know all the statistics the students have been taught , so that the basic nuts and bolts of clinical teaching can be enriched by these other domains; and the statistics knowledge be consolidated at the same time. This of course means we have to focus on what sort of staff deliver teaching, as much as the curriculum. I do not think we have got it right.

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