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The concept of integration (or holism) belies many ancient traditional beliefs and practices of the healing art. For example, the fundamental basis of traditional Chinese medicine, similar to the traditional Indian medicine (Ayurveda), is integration—the balancing between the forces within and between man and nature. In the context of modern (allopathic) medicine/medical education, the concept of integration is intuitively essential to the training of the well-rounded medical doctor, and not surprisingly, the history of modern medicine is awash with this time-honored concept, but it also reveals the periodic abandonment of its tenets and the attendant challenges. This editorial focuses on modern medical education and the challenges posed to, and by, the concept of integration in the medical curriculum and how this has impacted on the discipline of pharmacology. We address these challenges from historic (hence the various faces (phases)) and contemporary perspectives, borrowing largely from our observation in various medical schools where we have taught and/or have visited as scholar, and from the scientific literature. Information for the historic perspective of this discourse is drawn largely from the famous Flexner report of 1910, arguably the origin of modern medicine.
The history of modern medicine can be traced back a few centuries, but the one event that has impacted strongly on how we perceive, train, and practice medicine in the 21st century is the watershed Flexner's report of 1910 on medical education in the USA and Canada. The background to the Flexner's report was the perceived deterioration in quality of the training of physicians and in the practice of medicine. There was, among others, an erosion of the concept of integration, a free-for-all creation of medical schools with no quality control of entry qualifications, training, graduation, or subsequent practice. Medical schools existed without Teaching Hospitals, thus depriving the students a full opportunity for clinical exposure during their training. This was not always the case. Thomas Bond in conjunction with Benjamin Franklin had in 1752 established the Pennsylvania Hospital in realization, as he wrote then, that the medical student “must Join Examples with Study, before he can be sufficiently qualified to prescribe for the sick, for Language and Books alone can never give him Adequate Ideas of Disease and the best methods of treating them” (adapted from Flexner report p.4). This statement clearly indicates that as far back as the 1750s concern had existed about the concept of integration in medical education. The training of the medical student in North America of that era was purely didactic (Thomas Bond's “Language and Books”) and the call to “Join Examples with Study” was a clear call for the teaching of theory in clinical context. Flexner further wrote that Dr Thomas Bond argued successfully for the bedside training of the medical student and quoted him as saying, “…there the clinical professor comes to the aid of speculation and demonstrates the Truth of Theory by Facts.” Flexner in his report wrote, “The sound start of these early schools was not long maintained.” By the early nineteenth century, the pendulum had swung one full cycle with the establishment in Baltimore of a proprietary school, “the so-called medical department of the so-called University of Maryland” which according to Flexner set a harmful precedent that led to the proliferation of medical schools outside the purview of universities. This broke the traditions laid by Thomas Bond; a tradition that encouraged medical schools to emerge from (and thus, regulated by) existing universities, making them academic centers which were also part of a teaching hospital that created opportunities for “Join Examples with Study.” The harmful precedent of Baltimore created a movement in which proprietary medical schools proliferated, with the USA and Canada, in little more than a century, producing four hundred and fifty-seven medical schools, many of which were of questionable quality, many short-lived and only 155 surviving by the time of the Flexner's report. The integration concept espoused by Thomas Bond was then long jettisoned having been dealt almost a century of deadly blow.
The indiscriminate situation, which persisted into the 1880s, set the stage for Abraham Flexner's intervention. Around that same period progress in the sciences (physics, chemistry and biology) was increasing the physician's resources for diagnosis and therapy and with it the need to move medicine from empiricism to scientific basis and methods. Within these circumstances, the American Medical Association under the leadership of Dr N.P. Colwell sought for a neutral and unencumbered party- the Carnegie Foundation for the Advancement of Teaching- to undertake a study of medical schools in the United States and Canada. The president of the Foundation, Dr Henry Pritchett, commissioned Abraham Flexner (a non-physician, and former headmaster of a high school in Louisville, Kentucky) in 1908 to undertake the study, which culminated in the famous Flexner report of 1910. It was a very thorough examination of all aspects of medical education and it involved visits to all the 150 medical schools in existence then in the USA, Canada, and Newfoundland. Flexner made recommendations that could be summarized as follows:
Flexner's report served as a great beginning of what is today's modern medical education.[3,4] It brought significant changes not only to the training of the medical doctor but also to the growth and development of medicine. In the context of this discourse it impacted on medicine from two main perspectives:
Aided by the growth of Information and Communication Technology (ICT), the latter half of the last century witnessed an unprecedented rate of knowledge growth in medical (basic and clinical) sciences creating in its wake peculiar challenges to the traditional curriculum, including challenges to the learning/teaching of pharmacology. Growth in medical research propelled the emergence of new reductionist disciplines, such as genomics, proteomics, and molecular pharmacology. It can be argued that science drives teaching. With more and more knowledge at the cellular and molecular levels, teaching/learning in medicine tended to shift focus to these new reductionist fields, arguably, to the detriment of a holistic approach to understanding human physiology, pathophysiology, and, therefore, therapy. A lot of studies these days focus only on the molecular/cellular levels, despite the abundant evidence that results from these studies often fail in extrapolation to human application. Among the factors fuelling this phenomenon is the attitude of journal editors who tend to give precedence to such studies. Worried about this trend, individuals and professional bodies have warned against the lack of balance in the literature between the highly desirable reductionist studies and the equally desirable whole animal studies.[6–8]
By the middle of the last century it was increasingly observed that the reductionist attitude and strong subject discipline-based curriculum promoted medical curriculum in which the students tended to view the patient in a less than holistic manner. The traditional curriculum was perceived as deficient because:
It was the heightened recognition of these issues that led to the evolution of innovative curriculum in medicine,[9,10] the most prominent of which is the Problem-based Learning (PBL) paradigm and upon which the rest of this discourse is based.
The essence of the PBL paradigm is captured by the acronym SPICES curriculum which translates into self-directed learning, problem-based learning, integrated, community oriented, electives, and structured. The paradigm, in addition, promotes communication skills and team spirit. The one thread that runs through all innovative curricula is the concept of integration, considered essential to the promotion of holism. Integration of the medical curriculum has been variously described/defined.[12,13] We think of it as a holistic approach in which the basic medical sciences are taught/delivered as a composite of the individual disciplines and with clinical context in the early years of the curriculum (horizontal integration). In addition, the basic sciences are emphasized in the learning of clinical medicine in the latter years of the curriculum (vertical integration). It aims at inculcating in the medical trainee the attitude of perceiving the patient from a holistic perspective, applying the basic and clinical sciences in his approach to patient diagnosis and management.
The subject discipline-based departmental structures of the traditional curriculum have generally been viewed to exist, functionally and physically, in antagonism to the basic principles of integration. As a result the departmental structures have been dismantled in many innovative curricula.[14,15] This practice appeared to have enhanced the integration of the various subject disciplines as it removed the traditional barriers to cross-disciplinary interaction. The downside, however, is the emerging view that this practice may be posing resistance to the continuing growth of the various subject disciplines of medicine, including Pharmacology. The absence of the departmental structures has tended to translate into an absence of adequate protection/promotion of the interests/growth of the disciplines. This is particularly so in inadequately managed curricula. While various professional bodies have very rightly prescribed minimum requirements for a pharmacology/medical curriculum, consistent with the principles of integration,[16–18] there has been little discourse on the administrative structure best suited to achieving these curricular goals. We hold that while the dismantling of departmental structures tends to stand in antagonism to subject discipline autonomy and bloom, this antagonism is surmountable; the critical factor being the curriculum management capacity vis-a-vis the organizational culture. As an illustration, we have visited a medical curriculum where there are no officially designated discipline champions, despite the absence of the protective/promotive traditional departments. In such curricula the presence/visibility of the subject discipline (e.g. pharmacology) is left to the whims of those with power and of course to the extent of their internalization of the principles of, and adroitness in curriculum management. In our opinion, these qualities are unfortunately scarce. Under these circumstances, Pharmacology has been dealt a near-to-fatal blow in some medical schools. This situation is one which all professionals and professional bodies can only overlook with dire consequences for the future of pharmacology and medical education in general.
The problem has its roots in the phenomenon we hereby refer to as Power-Knowledge Dichotomy (PKD) in curriculum management. PKD in turn has its origins in yet another disease of the curriculum: “Postgraduate Degree does a Teacher Make” (PDTM). The traditional notion is that anyone who has obtained a postgraduate degree in any field (of medicine) is automatically fit to be a university (medical school) teacher. Such individuals are recruited into the medical faculty and do rise to become curriculum managers (even at the Dean level) and unfortunately often without formal teacher training. Reality however is that teaching or curriculum management is both a science and an art that requires a demonstrable depth of knowledge and skill which a formal teacher-training can only begin to cultivate. This reality is gaining currency with education authorities in some countries insisting on some formal teacher-training as a requisite for tertiary education teachers. With poor curriculum management many PBL curricula have failed to achieve the ideals that the PBL philosophy promises. Some have, therefore, fallen back to a second line of defense as it were by adopting the so-called hybrid curriculum, which is a mix of traditional teacher-centered, lecture-based delivery plus some degree of the student-centered PBL approach. A common feature of some failed PBL curricula is the marginalization of some subject disciplines, a result of a power game in which the subject/discipline experts without power fail to push their disciplines through the curriculum, whereas those with power tend to overwhelm the curriculum. This failure is compounded by the absence of the traditional protective departmental structures, which ensured the visibility of the discipline. For fear of this possibility among other factors, some PBL curricula have maintained the traditional departmental structures and with an impressive measure of success in curriculum integration. The challenge, therefore, is to strike a balance between the integration-enhancing absence of traditional discipline-based boundaries and the need to ensure the visibility and therefore, the growth and development of the discipline. Maintaining the traditional departmental structure is unacceptable in classical PBL thinking. We have, however, observed (as external examiner) that this appears to work well in some schools and may serve as a good alternative to be considered. It all comes down to curriculum management and the salient questions are:
One of India's best medical schools, which we recently visited as external examiner, professes the PBL philosophy. This school, however, has retained the traditional departmental structures, even as it consciously and rigorously pursued the concept of integration. We observed an impressive level of integration in the delivery and assessment of a well-defined pharmacology syllabus. In this medical school, early clinical exposure/immersion (ECE / ECI)—one of the major features of integration in a PBL curriculum-was practiced on departmental basis. Each traditional department had its own share of the ECE curriculum to deliver. Minor overlaps/repetition occurred between departments—a practice we consider pedagogically sound, being consistent with the principle of the spiraling curriculum: the promotion of growth and reinforcement of learning. Learning-teaching was also organ-system based with each of the traditional departments teaching and running PBL tutorials focused on the same curricular theme. In effect, the students learnt the anatomy, physiology, biochemistry, pathology, pharmacology, etc of the particular organ system within a particular learning/teaching block. This is not much different from what obtains in other hybrid PBL curricula which have dismantled the traditional departments. Lectures in such curricula are also discipline based even if the administrative units are not. Paraphrasing a feedback in a recent survey, our student said: “We still have to read anatomy, physiology and pharmacology textbooks, separately; the integration occurs in our heads.” This medical school, therefore, retained the benefits of the administrative structures of a traditional curriculum, yet made impressive leaps in integrated curriculum delivery; and that also with an ECE curriculum. It must also be pointed out that the traditional administrative structure existed only functionally, but not physically. This, for example, means that teachers of the Pharmacology department were not physically segregated from those of other disciplines; they shared common facilities, such as meeting places, and office rooms were not department-differentiated. This arrangement is thought to be capable of promoting faculty interaction, thus enhancing the concept of PBL and of interdisciplinary research collaboration. While classical PBL theorists may not accept the running of a PBL curriculum with traditional departmental structures, this Indian example points to the possibility of attaining the gains of both the innovative (PBL) and traditional curricula in a medical curriculum. That indeed may be the right model for schools that may choose the hybrid PBL alternative. The critical factor for success, in our opinion, is in curriculum managerial competence. In this regard, it is important to state that the Dean at the Indian medical school is a dyed-in-the-wool medical educationalist who has mentored and encouraged faculty development to a level that has been permissive of the type of development described herein. Perhaps it is also pertinent to state that there is a high percentage of medically qualified faculty in each of the traditional departments of the school—an important factor for integration.[5,21]
As observed above, the main challenge to Pharmacology in medical curricula without the traditional departments is related to the visibility of the subject in the curriculum. This in turn is tied to the challenge of who trains the pharmacologist of tomorrow. We are aware of such a school in which one external examiner after the other had raised the issue of a paucity of pharmacology questions in students′ assessments. This unacceptable situation arose purely from the absence of a Department of Pharmacology that would have ensured the visibility of the discipline in the curriculum. The recurrent nature of this observation (by various external examiners) is also a pointer to the potential danger of this type of curricular arrangement. The scenario arises (as in this particular case) where there is no formally identified discipline (pharmacology) champion with clear cut responsibility to take up the challenges highlighted by the series of external examiners. Even where a discipline champion existed he/she may not have the power of a traditional department to ensure visibility of the discipline. In the aforementioned school, there was no officially recognized discipline champion for pharmacology and the very few pharmacologists on board lacked the power to effect change. With little of pharmacology questions in the examinations, students were not motivated to study the subject. This school illustrates the great potential for failure of pharmacology (or any other discipline) in curricula without traditional departmental structures. It must be stressed, however, that such a failure does not necessarily imply an indictment of this curricular arrangement which, in our view, is philosophically sound and has worked well in other climes. The problem is in curriculum managerial competence. Power in a curriculum must go hand in hand with a deep sense of pedagogy, leadership, and curriculum managerial skills.
As discussed above, the concept of integration is as historic as it is inseparable from medical education. Even as curricular paradigms shift, integration would remain an issue. In the recent (2010) review of medical education since Flexner, the Carnegie Foundation Report recommended, among others, the promotion of multiple forms of integration, to include “the integration of formal knowledge of the basic, clinical, and social sciences with clinical experience in a much more balanced manner than is true today.” Given that health care requires multi-professional input, there has been a growing drive toward inter-professional education, which provides opportunities for inculcating team skills among healthcare professionals.[24,25] The Carnegie Foundation report of 2010 also emphasized on this, and we envisage that the actualization of this noble goal may pose challenges similar to those encountered in the attempt to integrate across subject disciplines in innovative (PBL) curricula. In some universities that we have visited, the different healthcare professions (such as Medicine, Dentistry, Pharmacy, and Nursing) are grouped under one administrative Dean/Faculty, partly to enhance inter-professional education, integration, and an anticipated healthcare team spirit. As the inter-professional education concept gains ground, it is reasonable to anticipate the emergence of new challenges to integration from this perspective and teachers of pharmacology (and other basic sciences) must gear up for these possibilities.
The Johns Hopkins University School of Medicine (JHUSM) was for Abraham Flexner the reference for excellence as he embarked on his survey in 1909. This school, 100 years after, has recently conducted a major review of its curriculum and has begun to introduce changes consistent with the general principles of integration espoused by Flexner, but updating same to reflect modern realities. The new curriculum, for example, promotes the integration of the modern science of genomics throughout what is referred to as the Gene to Society (GTS) curriculum. This laudable lead by JHUSM may yet gain a global recognition that may pave the way for new challenges to the concept of integration. This could be in the form of challenges in integrating genomics (and other new disciplines such as proteomics) horizontally and vertically in the curriculum, including the social, cultural, psychological, and environmental variables as envisaged by the GTS curriculum.
While the concept of integration has over the ages been considered critical in the training of the medical doctor, challenges have always existed in the implementation of this noble curricular notion. Innovative medical curricula in general uphold the concept of integration. Implicit to the growth and success of integration is the growth and development of the various subject disciplines that require integration. There is a growing fear that the dismantling of the traditional departmental structures (typically seen in innovative (PBL) curricula) threatens the regulation/growth/existence of the individual subject disciplines, such as pharmacology. On the other hand, the existence of these departments has been viewed as inimical to the goals of integration. Striking a balance is a desideratum, particularly as the worldwide reported increase in morbidity and mortality due to poor prescribing skill[27,28] cannot be separated from the perceived failure/decline in pharmacology curricula. Our observation is that given clear goals and the critical factor of competence in curricular management, any medical curriculum with or without departmental structures can achieve both integration and the growth of medical science disciplines. The critical factor is that all those appointed to manage a curriculum must be well trained (preferably through formal education) in pedagogy and curriculum management and such appointments should preferably be at the senior (at least a deputy Dean) level.
Source of Support: Nil.
Conflict of Interest: None declared.