How hard is it to integrate basic science and clinical learning?

How hard?  Not too hard…Ways to Integrate Science into the Clinical Courses (and vice versa)

integrate

For this blog, I need your help. And also I’ve tried something new.

First of all, I need help with some of the questions I’m positing. I’ve used questions used in activation of prior knowledge generally.  So please read them, and add your clinical know-how to them.

Secondly, I’m putting the theory last. I’m going to begin with practical ideas for integrating clinical and basic sciences in hopes you’ll agree that this is warranted.  I’ll put the reasons and the concepts behind integration later on at the end.

I’ll need your help with the practical too—what ideas do you have to integrate basic science and clinical concepts?

So… to get started:

You may think you don’t use basic science knowledge anymore.  Think about this case:

An adult patient comes into the outpatient office of
a doctor complaining of facial pain and nasal
obstruction for 2 days duration. Instantly, from these
2 signs, knowledge about acute facial pain pops into
the clinician’s mind, with sinusitis being especially
salient because of its frequency of occurrence in this
age group. This specific knowledge then orients the
questions asked and physical examinations administered.
A few minutes later, a new patient comes in
with vertigo signs. Instantly, knowledge about sinusitis
and facial pain is dismissed from active memory,
and knowledge of vertigo takes over. (Charlin, 2007).

Many physicians, encountering these patient presentations would react exactly as the physician above did.  We call the virtually unconscious use of basic science in this scenario “encapsulation.” (Schmidt, 2007) Alternatively,  a physician mobilizes organized knowledge in an “illness script.” (Charlin et al 2007, Schmidt, 2007) It’s not that you as a physician don’t use basic science–it’s just that experience, and practice has blended it seamlessly into your thinking.

But how can we get our students there? Of course, practice makes perfect and experience tells.  However, the  practice needs to be guided and scaffolded by good teaching and learning.  Here are some good teaching and learning interventions:

In pre-clerkship or clerkship:

  1. Be explicit about the science that grounds the clinical case or knowledge.  Insert science slides into your lecture/seminar slides that speak to basic science concepts at work.
  2. Use various media (words,pictures,practical experiences, lab results, microscope slides, etc.) to link science concepts to the clinical picture.
  3. Link to assessment. Critically, the assessment of integrated learring should reflect students’ sophisticated understanding of how the basic science relates to clinical understanding–not their ability to recall facts.   (Mandin, 2000).

In Clerkship:

Here are my ideas: What are yours?ideas 1

Provide opportunities for students to explore, research and strengthen their knowledge base of basic science issues relevant to commonly encountered clinical problems. Context is critical…for example, Laplace’s law describes fluid flow in the lungs which you can relate to asthma.

  1. Try: Case of the week? Case of the day? In rounds, or in a seminar, or in  Case of the Week such as Internal Medicine undertakes, consider questions for students to investigate:  What are the basic science issues that underlie this case? What is the pathophysiology at work here? (See Questions and Cues below.)
  2. Complement the mini-scholar CEX with a “Mini-science CEX”: ask students to use the same case as for their mini-Scholar CEX and inquire into the underlying science principles. Provide a worksheet or table for them to fill in that allows them to capture what you’re looking for. (See Questions and Cues, below.)
  3. Use some of the online modules developed for pre-clerkship as refreshers for clerkship. Students do this already.  Why not make it a part of the learning?

Need some help finding the modules? Ask an Educational Developer –we’re working with students to update the list.

OR

Work with one of the scientists in terms 1 or 2 and build one that will be useful from years 1-4.

  1. Bedside teaching: Ask a question about the underlying science of the case, in order to activate that learning.
  2. Questions and Cues that activate learning:

help from a docCan you help me provide some specific clinical applications?

 

Cues and Questions:questions you could ask

  • What organ system(s) draws your attention here?
  • How does this system normally work?
  • What normally happens?
  • What’s likely to have interrupted the process here?
  • What does that look like? What changes does that precipitate?
  • What are the basic processes used in reaching this state?
  • What changes occur when someone reaches this state?
  • What influences:  the quality, location, duration, precipitation, course of symptoms
  • What could be misleading you (confounding)?
  • What are limitations to your knowledge of this?
  • Use this blank schema/organizer to illustrate what is going wrong…(you’ll have to fill this one in!)

Now, you can see that your questions will be better than mine. Please write in with them!

Clerkship and Pre-Clerkship:

I found  some examples of questions in Bierer et al’s work, Methods to assess students’ acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum in Medical Teacher. Their examples come from a first year course (!) that integrates science and clinical teaching. Please read about what they do in the article, but here are some of the questions:

  1. What are the urea and creatinine clearances in ml/min and L/day?
  2. If they are not the same as inulin, explain the difference.  Which substance provides the most accurate estimate of glomerular   flitration rate?
  3. How is it possible that the volume of urine is so high with such a low inulin clearance?
  4. In the above patient, assuming that the daily intake of sodium chloride is 5g, the plasma sodium concentration is 140mEq/L and the 24 h urine sodium excretion is 86mEq,

o   What percentage of filtered sodium is being excreted?  Reabsorbed?

o   Is the patient in sodium balance?

o   What does this information tell you about the kidney’s role in sodium homeostasis?

I like these Self-Assessment Questions too:

1. The renal clearance of inulin and creatinine are different. What explains this?

A.  Creatinine is not freely filtered through the glomerulus, whereas inulin is.

B.   Creatinine is only filtered while inulin is both filtered and secreted.

C.   Creatinine is both filtered and secreted while inulin is only filtered. *

D.   Creatinine is metabolized in the urine while inulin is not.

 2. Which of the following events is most likely to result in lower extremity edema?

A.   Low capillary hydrostatic pressure

B.   High plasma oncotic pressure

C.   Low plasma oncotic pressure *

D.   High tissue oncotic pressure

3. The majority of glomeruli are found within which region of the kidney?

A.  Calyces

B.   Cortex *

C.  Infundibula

D.  Medulla

E.   Papilla

 

Some Great Examples in Pre-Clerkship examples

We have some great examples of how to do this in our curriculum. The  key is the spiral curriculum where a student revisits a topic, theme, or subject several times, in deepening complexity (including science helps increase complexity), and a new learning relationship attached to old information. You’ve heard me talk about this before. See below for the theory and my conception.

Nowhere does this make sense more than in the clinical application of concepts from basic science.  For the first 2 years, here at Queen’s, there are some excellent examples of this.  Many of these came from a Curricular Leaders’ Retreat last year, with my thanks!

Have you clerkship examples?  Please send them here!

  1. Develop a weekly or monthly, undifferentiated case, where possible, “Case of the Week”, either in pre-clerkship or clerkship, to look at 20 main opportunities or “boluses” or “nodes”.   In clerkship these can be sent electronically, similar to “NEJM” Case, to create an online curriculum. Focus can be given to special populations. Course Directors would need to get together to do this to include the Course Directors from year 1. Year Directors can provide a focus.
  2. Dr. Romy Nitsch in Obs/Gyn has created an excellent introductory lab idea. Contact Dr. Nitsch for ideas.
  3. GI/Surgery and Neurology are trying a similar approach during the first week of the courses. Neurology is trying an online “diagnostic” test to assess student retention of anatomy and other scientific themes. Students who fall below a threshold will be required to participate in a tutorial. See Dr. Stuart Reid for ideas.
  4. Shared or Team Teaching: Dr. Sue Moffatt has worked with Dr. Conrad Reifel in his NHS course and Dr. Les MacKenzie has taught in Dr. Moffatt’s Respirology unit. See attached handout for ideas, or contact one of the participants.
  5. In Renal part of Endocrine/Renal, Dr. Jocelyn Garland and Dr. Iain Young work to show a “real time pathology consult” for each case. See Drs. Garland or Young for ideas.
  6. In therapeutics, it’s important for students to understand the visual process of how a drug works and the mechanism of the action. Students are provided with clinical cases from internal medicine to illustrate different mechanisms. In future, goals are to develop sessions/modules around classes of medicines for specific courses e.g. antibiotics and asthma meds for pediatrics/ beta-blockers for cardiology, etc. As well, the evidence base for use of these therapies is important.
  7. Bring clerks into pre-clerkship sessions you’re teaching. E.g. if you’re teaching about Acid Base in Renal/Endocrine, bring clerks from the service into the class to assist students with the learning and to show how it’s applicable to them in future. Can also occur in first year courses.
  8. Build online resources that may be used in different ways by different faculty in the future into clerkship. E.g. Sodium/Acid Base. Consult the foundational science faculty for assistance, as they have a huge database of images for use.
  9. OR consult the library for existing modules that may be used similarly. There are several videos, and other media, such as Anatomy TV which may be used.
  10. Use the Clinico-Pathologic Conference Approach used in the NEJM cases (examples at http://oac.med.jhmi.edu/cpc/links.cfm) where a case is presented to a clinician, who then demonstrates the process of reasoning that leads to his or her diagnosis. A pathologist then presents an anatomic diagnosis, based on the study of tissue removed at surgery or obtained in autopsy. Students work on the diagnosis, and discussion ensues.
  11. Who could be involved in preclerkship or clerkship? See how these faculty and concepts are located around a single node or bolus?

node

Great Places to Integrate

places for integration

We have some places in pre-clerkship that are waiting for some basic science; and some great places that are waiting for some clinical applications.

  1. In FSGL, we have the opportunity to integrate pathology, anatomy, imaging, etc. into cases.
  2. In Expanded Clinical Skills, there exist spaces for this integration.
  3. Problem solving exercises in SGL require foundational science for solutions and diagnoses. See above re. cases for some examples.
  4. CAUTION: Don’t overload. Use these examples of integration judiciously. Perhaps imaging is all that Dr. Davidson will use in a case of a limping child. Or perhaps Dr. Murray will use knowledge of histology and pathology or drug therapies in a case of a female patient presenting with shortness of breath that could be a case of myocardial infarction.
  5. Looking for some places and people with which to integrate?
  • In term 1, we teach Normal Human Structure (anatomy/histology), Normal Human Function (Physiology) and Critical Appraisal, Research and Learning (Epidemiology, stats, methods of study).
  • In term 2 we teach Therapeutics (pharmacology) and Mechanisms of Disease (immunology, infection, pathology). We teach about neoplasia, etc. in Blood and Coagulation. Genetics is taught in Genetics and Pediatrics in Term 2.
  • In the C courses, many concepts are bundled together, often by faculty who taught in pre-clerkship.

Some Theory:

As promised, here’s the theory (with a few practical applications to keep you reading)

theory 2

What is integration?   It refers to situations in which knowledge from different sources (basic science, clinical, factual, experiential, etc.) connect and interrelate (Regehr, 1996) in a way that fosters understanding and performance of the professional activities of medicine (diagnosis, management,etc.). (Kulasegaram, 2013).

  1. Integration of concepts is a two way street. We may bring aspects of clinical cases back to foundational Basic Science Courses. We may bring aspects of basic science and other concepts into clinical courses and clerkship.
  2. The key to this is communication, and knowledge of what each other is teaching.

See Integrating across years and courses: Lessons learned in NHS and Circ/Resp Handout attached. Educational Developers and Year Directors know what’s going on in the whole curriculum.

  1. Integration works in many ways from year 1 to year 2 and vice versa, and from year 1 to year 2 to clerkship and vice versa.
  2. Think of integration as “booster dose” to increase learning. Foundational courses provide the initial “vaccine” but students require booster doses to boost their learning.
  3. A “spiral curriculum” is a curricular model where students revisit specific aspects of previous learning but build on it to move forward. Integration is the key concept here. See below.

Integrated teaching offers many advantages (Harden, 2000)and may be a key factor in the delivery of an effective educational programme.

For the following, I am indebted to Kulasegaram, KM et al. (2013) in Cognition Before Curriculum: Rethinking the Integration of Basic Science and Clinical Learning.

Kulasegaram et al write, “Causal integration is not just an aid for memory and retention (Woods, 2007).  Rather, the cause and-effect relationship between the basic sciences (such as the physiology of upper motor neurons) and clinical features (such as the symptoms of stroke) creates a framework within learners’ minds that allowed them to organize the constellation of the features of a diagnosis. (Woods, 2007). This cognitive conceptual coherence is the advantage of integrated basic science teaching.” See this excellent article for more theory behind integration.

In a spiral curriculum, “a curriculum as it develops should revisit this basic ideas repeatedly, building upon them until the student has grasped the full formal apparatus that goes with them” (Bruner, 13).  Different terms are used to describe such an approach, including “distributed” and “spaced.” A spiral approach is often contrasted with “blocked” or “massed” approaches.

In a spiral curriculum,

  • The student revisits a topic, theme or subject several times throughout their school career.
  • The complexity of the topic or theme increases with each revisit.
  • New learning has a relationship with old learning and is put in context with the old information.

The benefits ascribed to the spiral curriculum by its advocates are:

  • The information is reinforced and solidified each time the student revisits the subject matter.
  • The spiral curriculum also allows a logical progression from simplistic ideas to complicated ideas.
  • Students are encouraged to apply the early knowledge to later course objectives.

Here’s how I envision our spiral curriculum at Queen’s. What do you think? Advice and feedback most welcome!

sheila arrow-2

References

These articles are either cited above, or were consulted in putting these arguments together.

Bierer, S. B.,  Dannefer, E .F., Taylor, C., Hall, P. (2008).  Methods to assess students’ acquisition, application and integration of basic science knowledge in an innovative competency-based curriculum. MedTeach.30.

Bruner, Jerome. (1960). The Process of Education. Cambridge, MA:  The President and Fellows of Harvard College.

Charlin, B. et al. (2007). Scripts and Clinical Reasoning.  Medical Education, 41(12).

Harden, R. (2000). The integration ladder: a tool for curriculum planning and evaluation.  Medical Education, 34(7).

Harden, R.M., Sowden, Susette, Dunn W.R. (1984). Some educational strategies in curriculum development: The SPICES model. Medical Education. 18 (4).

Kulasegaram, KM et a.(2013). Cognition before curriculum: Rethinking the integration of basic science and clinical learning. Academic Medicine, 88 (10).

Mandin, H. (2000). Evaluation: The engine that drives us forward—or back.  Clin Invest Med., 23 (1).

Regehr, G, Norman, GR. (1996). Issues in cognitive psychology: Implications for professional education. Acad Med., 71(9).

Schmidt, H. G. & Rikers, R. M. J. P.  (2007). How expertise develops in medicine: knowledge encapsulation and illness script formation. Medical Education, 41(12).

Woods, N. (2007). Science is fundamental: the role of biomedical knowledge in clinical reasoning. Medical Education, 41 (12).

Woods, N.N., Brooks, L.R., Norman, G.R. (2007). It all makes sense: Biomedical knowledge, causal connections and memory in the novice diagnostician. Adv Health Sci Educ Theory Pract., 12(4).

 

 

 

 

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