lessons learned about integrating a medical school curriculum: perceptions of students, faculty and...

Lessons learned about integrating a medical schoolcurriculum: perceptions of students, faculty andcurriculum leadersJessica H Muller,1 Sharad Jain,2 Helen Loeser3,4 & David M Irby2,5

OBJECTIVE Recent educational reform in US medicalschools has created integrated curricular structures.This study investigated how stakeholders in a newlyintegrated curriculum – students, course directorsand curriculum leaders – define integration andperceive its successes and challenges during itsfirst year.

METHODS We conducted interviews with curriculumreform leaders, course directors and first year medi-cal students. Interview transcripts were analysed forthemes, which were compared within and acrossstakeholder groups.

RESULTS Three curriculum leaders, four Year 1course directors and six Year 1 medical students wereinterviewed. Fifteen students participated in a groupinterview. Four major themes emerged: inter-disciplinary teaching; interdisciplinary faculty collab-oration; building curricular links, and sequencingand framing curricular content. Cross-group analysisrevealed participant agreement that an integratedcurriculum required interdisciplinary teaching,clinical application and careful oversight. Differencesamong groups were also identified. Faculty (course

directors and curriculum leaders) discussed facultycollaboration and the challenges of faculty buy-in andcourse implementation. Students highlighted theimpact of integration on their learning and thechallenges of sequencing and scaffolding content.Both students and course directors focused on coursemonitoring and conceptual links for studentlearning.

CONCLUSIONS Integrating a curriculum is a complexprocess. It is differentially understood and experi-enced by students and faculty, and can refer toinstructional method, content, faculty work or syn-thesis of knowledge in the minds of learners. It canoccur at different rates and some subjects are inte-grated more easily than others. We point to somespecific considerations as medical schools embark oncurriculum reform.

KEYWORDS *education, medical, undergraduate; *schools,medical; *curriculum; teaching; interprofessional relations; faculty;United States.

Medical Education 2008: 42: 778–785doi:10.1111/j.1365-2923.2008.03110.x

INTRODUCTION

During the past decade, integrated curricula havebecome the norm in North American medicalschools.1,2 Although there is no one definition forcurricular integration,3 it typically refers to interdis-ciplinary block courses in pre-clerkship years thatbring together basic, clinical and social sciences intoone course, or weave longitudinal curricular themesacross the curriculum (e.g. ethics).4–8 Integratedcurricula have been widely adopted, fuelled bydissatisfaction with the way basic sciences have beentaught as individual disciplines with no clinicalapplication and by growing recognition that

curriculum: opinions and progression

1Department of Family and Community Medicine, School ofMedicine, University of California San Francisco, San Francisco,California, USA2Department of Medicine, School of Medicine, University ofCalifornia San Francisco, San Francisco, California, USA3Department of Pediatrics, School of Medicine, University ofCalifornia San Francisco, San Francisco, California, USA4Office of Curricular Affairs, School of Medicine, University ofCalifornia San Francisco, San Francisco, California, USA5Office of Medical Education, School of Medicine, University ofCalifornia San Francisco, San Francisco, California, USA

Correspondence: Jessica H Muller PhD, Department of Family andCommunity Medicine, Box 0900, University of California SanFrancisco, San Francisco, California 94143-0900, USA.Tel: 00 1 415 476 5175; Fax: 00 1 415 476 6051;E-mail: [email protected]

778 ª Blackwell Publishing Ltd 2008. MEDICAL EDUCATION 2008; 42: 778–785

traditional instructional modes no longer meetcurrent demands for interdisciplinary inquiry andpractice in medicine.7,8 At the same time, cognitivetheories of learning suggest that an integratedapproach to education may have important benefitsfor learning and retention because it facilitatescontextual and applied learning, and can promotedevelopment of the well organised knowledge struc-tures that underlie effective clinical reasoning.9–12

The medical education literature contains numerousstories of curriculum change.3,13–17 A few studiesalso report programme outcomes: students trainedwithin an integrated curriculum made moreaccurate diagnoses than did students trained in aconventional curriculum;18 vertical integrationbetween basic sciences and clinical medicine inproblem-based learning curricula stimulated betterunderstanding of biomedical principles than didconventional curricula,19 and a high degree ofhorizontal integration occurred in the early years,but more input from clinicians was neededthroughout the curriculum to achieve vertical inte-gration.20 Conceptual approaches to integrationhave also been proposed. Harden21 argues thatcurricular integration can be viewed as a ladder, withdiscipline-based teaching (�isolation�) at the bottom

of the ladder and full integration (�trans-disciplinaryteaching�) at the top.

Although interest in integrated curricula is growing,little attention has been paid to the perceptions ofdifferent stakeholder groups – the leaders ofeducation reform, the students directly affected bycurriculum change, and the directors of newly inte-grated courses – especially during the transition froma traditional to an integrated model.4,8 The aim ofthis study was to explore the meaning of integrationto students, faculty members and curriculum reformleaders and to compare and contrast the perceptionsof students and faculty of the successes andchallenges of curriculum integration during thefirst year of reform.

METHODS

Setting and study participants

A major curricular transformation was launched atthe University of California San Francisco (UCSF)School of Medicine with the incoming class in 2001.13

The traditional lecture-based, departmentallysegmented pre-clerkship curriculum was redesignedto emphasise interdisciplinary approaches toteaching, small-group and case-based learning,and the application of basic science to patient care.The new model included: eight interdisciplinaryblocks in the first 18 months of medical schoolthat were planned, administered and taught byfaculty from basic sciences, social and behaviouralsciences and clinical academic departments;a clinical core year, comprised of core clerkships,intersessions and longitudinal clinical experiences,and an advanced studies year, includingsub-internships and electives in areas ofconcentration (Fig. 1).

Using a purposive sampling strategy,22 we identifiedstudy participants in the following groups: facultyleaders who were drivers of educational reform;directors of new Year 1 courses, and Year 1 studentswho were taking an active role in curricular changeactivities.

Design and data collection

To best explore participants� perceptions andinterpretations of their experience, we selected aqualitative research design using semi-structuredinterviews.23 Having gained approval from the insti-tutional review board, we conducted this research

Overview

What is already known on this subject

Integration is a central theme of medical schoolreform, but little is known about how differentstakeholders perceive this curricular change.

What this study adds

Curriculum leaders, course directors and stu-dents shared their perceptions of integration.All parties identified interdisciplinary teaching.Course directors and curriculum leadersdescribed interdisciplinary faculty collaboration.Course directors and students spoke aboutcurricular links. Students identified the need forcurricular sequencing and frameworks.

Suggestions for further research

Research is needed to understand thegeneralisability of these results and to trackstakeholder perceptions as a new curriculummatures.

ª Blackwell Publishing Ltd 2008. MEDICAL EDUCATION 2008; 42: 778–785 779

Integrating a medical school curriculum

over a 6-month period at the end of the first year andthe beginning of the second year of the newcurriculum. Two of the authors (JM and SJ),conducted individual semi-structured interviews(Appendix 1). To triangulate methods,24 we alsoconducted one group interview of Year 1 medicalstudents. We stopped interviewing at the point ofdata saturation, when interviews yielded no newinformation about themes.25,26 The interviews,which lasted 30)60 minutes, were audiotaped andtranscribed.

Data analysis

Data analysis was carried out in five stages. Followinggrounded theory methodology,26 two authors (JMand SJ) initially read the interview transcripts anddevised a coding framework based on emergingthemes. After coding transcripts individually, theymet to conduct between-coder comparisons untilthey agreed on the meaning and application of thecodes. The process was conducted again with all fourauthors, who individually coded samples of theinterviews before meeting to assess inter-rater reli-ability. After extensive discussion, they too reachedagreement about the definition of coding categoriesand themes and their application to the data underconsideration. Using constant comparison toensure consistent coding, the primary authors thenanalysed the remaining interviews. Once the datawere organised using NVivo,27 a qualitative dataanalysis software program, the researchers analysedthe thematic categories within and across stakeholdergroups. A theme was attributed to a stakeholdergroup if most or all members of that group madecomments relating to that theme.

RESULTS

Individual interviews were conducted with threemembers of the educational leadership team (vice-dean for education, associate dean for curricularaffairs and chair of the curriculum committee), fourYear 1 course directors and six Year 1 medicalstudents. In addition, 15 students participated in thegroup interview. Four major themes emerged inparticipants� discussions of what an integrated cur-riculum meant to them and how they perceived thesuccesses and challenges of the new curricular model:

1 interdisciplinary teaching;2 interdisciplinary faculty collaboration;3 building curricular links, and4 sequencing and framing curriculum content

(Table 1).

Analysis across the three stakeholder groups revealedboth commonalities and differences, which arediscussed below for each theme. Illustrative quoteshave been edited slightly for ease of reading.

Interdisciplinary teaching

All stakeholder groups characterised an integratedcurriculum as the interweaving of disciplines to teacha subject from multiple perspectives. An exampleof successful interdisciplinary teaching was instruc-tion related to the cardiovascular system. In onecourse, students learned about the physiology ofblood circulation, the anatomy of the heart, thecardiac examination, medications, behaviouralchange to prevent cardiac disease and health care

Year 1 Prologue

1-3

Organs

Advanced studies

Year 3 begins

Year 4 begins

Advanced studies Advanced studies

Organs Cancer

Metabolism & Nutrition Life cycle Clinical block 1 2

3 4 5 6

BMB

August October November December

Vacation

Vacation

Vacation

Vacation

Vacation

Intersession 1

Intersession 2 Intersession 3

Integration & Consolldation

Clinicalinterlude

Foundations of patient care

Foundations of patient care

Longitudinal clinical experience

Infection, Immunity & Inflammation

Vacation

Looking ahead Brain, Mind & Behaviour

January February March April May June JulySeptember

Year 2

Year 3

Year 4

Figure 1 The integrated curriculum


J H Muller et al

disparities. The clinical contextualisation of basicscience provided another example of effective inter-disciplinary teaching. A curriculum leader noted:

�I think the most obvious way that people haveperformed a uniformly good job is integrating basicscience with clinical science and really creatinginterplay between these two disciplines.�

Students found that the clinical cases and interac-tions with actual patients helped them synthesise andretain basic science knowledge. They particularlyliked the dramatic presentation of one case at thebeginning of Year 1, which became an anchor formultidisciplinary instruction throughout the year.According to one student:

�[Integration] makes learning more enjoyable, moremeaningful, and it makes much better clinicians. Weare learning about the neurobiological aspects ofsubstance abuse and addiction. Tomorrow we aregoing to have a psychiatrist lecture. Today weinterviewed a patient with an addiction. When wesee people, it all comes together.�

At the same time, members of all stakeholdergroups pointed out how interdisciplinaryapproaches had not worked well with certainsubjects and teaching modalities. Several studentscommented that histology and anatomy had notbeen taught in an integrated fashion, and bothstudents and faculty observed that the social andbehavioural sciences were not well integrated intothe rest of the curriculum. In addition, allparticipants found that many lectures remaineddiscipline-specific, making them the least integratedof all teaching methods.

Interdisciplinary faculty collaboration

To course directors and curriculum leaders, but notstudents, integration also referred to the interdisci-plinary faculty teams created to plan, administer andteach the new block courses. When asked whatintegration meant to her, a course director replied:

�The first thing that comes to mind is sitting aroundthe table with members of different departments anddifferent disciplines… and recognising that this wassuch a different mix than in the old curriculum,where the faces around the table were largely fromone or two disciplines.�

At the same time, faculty recognised that the tradi-tional �siloed� disciplinary perspectives of academicmedical centres made collaboration across academicboundaries difficult. They described the hurdlesfaced in gaining the initial co-operation of some basicscience department chairs, who opposed the inter-disciplinary nature of the new block courses anddoubted the pedagogical soundness of moving to anew curricular model. Course directors in particularspoke of the challenges presented by interdisciplinaryfaculty. Their co-directors often came from differentdisciplines and did not share the same disciplinaryassumptions or pedagogical practices. Moreover,course directors had to co-ordinate a large group ofteaching faculty who came from disparate academicfields or clinical specialties and did not routinelycommunicate with each other. Faculty membersacknowledged that obtaining faculty buy-in for thenew curriculum would have been difficult without thesupport of the dean, who provided oversight,resources and a compelling vision of educationalreform.

Table 1 Themes identified by different stakeholder groups

Themes

Stakeholders

Students Course directors Curriculum leaders

Interdisciplinary teaching X* X X

Interdisciplinary collaboration X X

Building curricular links X X

Curricular sequencing and frameworks X

* �X� in a cell signifies that the theme emerged in that stakeholder group; a blank cell denotes that the theme did not emerge in that group



Despite these challenges, several block leadershipteams emerged that effectively combined faculty fromdifferent disciplines, as described by this curriculumleader:

�The directors of the Organs block [cardio ⁄ respira-tory ⁄ renal organ systems] were a great team becausethey merge a basic scientist and a clinician. Sowhenever they were looking at content issues, theyhad both eyes on it. And that works extraordinarilywell. That�s the real joy in this process; it is a learningprocess for those involved as well as for the students.�

Building curricular links

Course directors and students defined integration interms of co-ordinated curricular components andfaculty who understood the overall curriculum andmade conceptual links between new and previouslylearned material. Students in particular viewed theselinks as essential in a curriculum where differentsubjects and disciplinary perspectives wererepresented in one block. This was one area wherestudents believed the curriculum often fell short.They described numerous missed opportunities forachieving true integration because their teachers didnot know the curriculum beyond their own lectures,did not communicate with one another, made noeffort to discover what content had already beencovered or what students would be learning in thefuture and failed to link their subject matter with therest of the curriculum. As a result, redundancies andgaps occurred:

�We get certain really basic things repeated over andover again, and then some basic things not taught atall because there is not communication betweendisciplines.�

Students as well as course directors felt thatco-ordinating and monitoring curriculum contentshould be the responsibility of course directors, asthis student observed:

�A good course director sits in on every lecture toquestion what we did not cover, what to carryforward.�

At the same time, both faculty and studentsacknowledged the challenge of maintaining curricu-lar threads when content was dispersed within andacross blocks. Students appreciated the efforts ofcourse directors to build planned redundancies intothe block curriculum, so topics covered earlier in theblock could be revisited. They also found it more

effective if one individual took responsibility forlinking content in the longitudinal curricular themesthat were threaded through multiple block courses.As one student stated:

�One good example where integration has worked ispharmacology, which has been stratified througheach block, where we have the same individual whotaught pharmacology in the previous block buildupon it for this block.�

Sequencing and frameworks

Sequencing and framing of curricular contentemerged as a fourth theme, identified primarily bystudents. Some students found that the curriculumlacked organisation, whereas others worried that theywere being given advanced content before they hadlearned basic terminology or concepts:

�Part of the issue of the curriculum is not the contentbut the organisation. Part of integrating is decidingwhen to present certain information… And some-times I have difficulty seeing the logic or the rationalebehind how they organise the block.�

Students also expressed the concern that they werenot getting a solid foundation in some of the corecontent knowledge and that their teachers were notproviding sufficient overviews or conceptual frame-works for curricular material. These overviews andframeworks were seen as crucial elements of anintegrated curriculum because they provide both acontext and a roadmap for learning. Without them,students found it difficult to bring together disparatesubject matter and to build their own integratedrepresentations of course material:

�If you become practised at thinking about things inan integrated fashion, it becomes easier and you haveone step up when you�re actually in practice. It�s likelaying the groundwork in your mind for how yougo about thinking about things. But there has to besome support system and background so that youhave confidence creating this foundation.�

DISCUSSION

This study, which took place at the end of the firstyear of a major curricular transformation, foundconsiderable congruence among curriculum leaders,course directors and students. All stakeholdersagreed that an integrated curriculum requires inter-disciplinary teaching, clinical application of basic


J H Muller et al

science material and course directors who providedetailed course oversight. They also agreed on manyof the challenges, including: achieving truly interdis-ciplinary lectures; overcoming the reluctance offaculty to shift to a new curriculum model; gettingfaculty to communicate with one another, andestablishing oversight and continuity of themes acrosscourses.

We also found differences between groups. Thefaculty involved (course directors and curriculumleaders) perceive the issue through a different lens tothat of students. Faculty spoke of their challenges incourse planning and implementation, whereasstudents emphasised content sequence andco-ordination. Faculty focused on collaborativeinterdisciplinary course leadership, which was notmentioned by students. Students consistently com-mented on the impact of integration on theirlearning, which was enhanced when instructors madelinks between different subjects, built on whatstudents knew and offered conceptual frameworks.Course directors bridged the perspectives andinsights of both curriculum administrators andstudents. They shared with curriculum leaders abelief in the importance of collaborative interdisci-plinary course leadership and concurred withstudents that it is important to have oversight ofthemes and teaching across courses and small groups,and to provide conceptual links for student learning.

This research suggests several lessons learned aboutintegrating curriculum. Firstly, it identifies theimportance of providing conceptual frameworks forlearning. In discipline-based courses there arecommonly shared assumptions about content pro-gression, curricular priorities and teaching methods,whereas in integrated block courses the directors arerequired to create new, larger conceptual frameworksencompassing multiple disciplines that may notshare common assumptions or approaches. Thecurriculum must be organised in such a way as topermit scaffolded instruction,28 so teachers canprovide sufficient guidance to address gaps in studentknowledge and skills. Students desire conceptualframeworks and scaffolds but most course directorsand teachers were initially either unable to providethem or did not recognise the need for them. Theability of the faculty and the curriculum to conveycontent in instructionally powerful ways that aredirectly relevant to learners� developmental level –what Shulman,29 Irby30 and others call �pedadogicalcontent knowledge� – may take several years toacquire and remains one of the biggest challengesfacing an integrated curriculum.

Secondly, integrating a curriculum is a more complexand uneven process than Harden�s21 hierarchicalcontinuum of integration suggests. We found thatsome subjects and disciplines lend themselves moreeasily to integration than others, resulting in acurriculum that is more integrated in some areas andless in others. The integration process occurs atdifferent rates, with different emphases and commit-ments over time. Integration may be differentiallyunderstood and experienced by students and faculty,and can refer to rearrangements of content, innova-tive instructional methods, faculty work or thelearning that takes place in the minds of learners.4

Mirroring the experience of other schools, this studyreveals the importance of co-ordination and jointplanning between teachers from different disciplines,as well as the importance of an organisationalstructure with appropriate resources and effectiveleaders who define and promulgate their vision ofeducational reform. As other reports have shown, thisstudy demonstrates that a case-based approach effec-tively promotes integration among basic, clinicaland social sciences, and that clinical contexts may befundamental to successful integration.4,9–11 Facultyand students in this study recognised the benefits ofan integrated curriculum for learning and retention,emphasising that learning is enhanced when it ismeaningful, relevant and learned in the context inwhich it will be later recalled.

We also encountered some of the same pitfallsexperienced by other schools. Although architects ofthe new curriculum envisioned courses as well asindividual lectures that were truly interdisciplinary,this goal was not always achieved.4,21 Similar to otherinstitutions, we faced the challenges of integratinglongitudinal curricular material without losing thecurricular thread and of integrating the social andbehavioural sciences into the curriculum.4,5

Limitations of our study include a small sample ofindividuals who planned, implemented and partici-pated in the new integrated curriculum in the initialyear of implementation. Moreover, our findings arefrom a single institution and may not generalise toother schools. It must also be emphasised that thisstudy was performed at the end of the transition yearto the new curriculum, when the integrated modelwas still tentative and all involved in curriculumreform were learning how to deliver an integratedcurriculum as they proceeded with implementation.Integrating a curriculum is an evolutionary processand significant changes have been made at UCSFsince the time of this study. There is now more



co-ordination of material within and among blockcourses and faculty are providing more conceptualscaffolding and overviews of curricular material. Inaddition, some of the initial concerns about studentlearning have been dispelled as student performancein the new curriculum has equalled or surpassedthat in the old disciplinary curriculum.

In summary, this case study illustrates the keysuccesses and challenges involved in integrating acurriculum in the eyes of its stakeholders during thefirst year of implementation. Although students,faculty and curriculum leaders share similar per-spectives on many aspects of curriculum integration,they also have differing perceptions of what integra-tion means, how it succeeds and where it facesimportant challenges. For an integrated curriculumto succeed, these different perspectives should begiven voice as medical schools envision, plan andembark upon redesign of their undergraduatemedical education curricula.

Contributors: JHM had primary responsibility forconceiving and designing the study, collecting andanalysing data, and writing and revising the manuscript. SJshared responsibility for the study conception and design,data collection and analysis, and manuscript revisions. HLand DMI analysed and interpreted data, and edited andreviewed the manuscript for important intellectual content.Acknowledgements: the authors would like to acknowledgethe participants in the 2002 Harvard Macy Institute for theirinput into the conceptualisation of the project andDr Patricia O�Sullivan for her contribution to the reviewand revision of the manuscript.Funding: this research was partially funded through theHaile T Debas Academy of Medical Educators and theOffice of Medical Education, University of California SanFrancisco.Conflicts of interest: none.

Ethical approval: this study was approved by the Committeeon Human Research, University of California San Francisco.

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APPENDIX 1. INTERVIEW GUIDE

1 I would like to start off with a very general question.When you hear or use the word �integration�, what does itmean to you?2 How do you think others involved in the new curriculumdefine integration?3 What types of integration have you seen in the newcurriculum?4 Where in the new curriculum do you think efforts atintegration have been particularly successful? Why?5 Where have they been less successful? Why?6 What barriers or challenges to integration have youencountered or heard about?7 Now that we are at the end of the first year of the newcurriculum, how have your perspectives on integrationchanged with time?8 Where would you like to see the curriculum go from herein terms of integration?

Received 2 May 2007; editorial comments to authors 10 September2007; accepted for publication 11 February 2008



lessons learned about integrating a medical school curriculum: perceptions of students, faculty and...

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