Vertical integration in the teaching of final year medical students

Dear Editor, The traditional approach to medical education
has been dichotomous, with a lack of
integration between basic sciences and clinical
medicine (1). Recent reforms have called for
individualizing the learning process, integrating
knowledge with practice, and cultivating a spirit
of lifelong learning (2). Vertical integration
breaks the traditional division between clinical
and pre-clinical sciences, resulting in better
understanding and application of concepts (3).
We did an exercise to integrate basic sciences
and clinical medicine in the teaching of medical
students. After obtaining informed consent
and ethical clearance, a group of final year
undergraduate students underwent vertically
integrated, small group, problem-based training
on tuberculosis. We studied the effect of the
integration on the students’ understanding of the
subject and acceptance of this method. Students
were divided into intervention and control arms
of 10 students each, based on the medical units
in which they were posted. The control arm
underwent standard clinical teaching (lectures
and practical sessions), as per the institutional
education policy. The intervention group was
given three case scenarios which highlighted
the various presentations of tuberculosis, with
relevant questions regarding the pathogenesis,
clinical course, and management. These were
discussed in a multidisciplinary interactive
session, with input from the faculty taken from
the departments of Pathology, Microbiology and
Internal medicine. Triangulation of data from
pre- and post-test scores, focus group and feedback scores was done.
When compared to the mean pre-test score,
the mean post-test score in the intervention
group significantly improved (6.7 vs. 12.44, mean
difference: 5.74; 95% CI 2.71-8.95; p=0.003).
There was a significant difference in the mean
post-test scores between the intervention and
control groups (12.44 vs 7.55, mean difference:4.89; 95% CI 3.89-5.84; p<0.001). On qualitative
assessment by focus group discussion, the students
stressed on the usefulness of the session and felt
that vertical integration facilitated “integration
and application of knowledge”. They were able to
“recognize how diverse processes are inter-related”.
The problem-based approach motivated them to do
self-directed learning and facilitated formulation
of research ideas. In their own words, “The onus
of the learning was in our hands, so we learnt
better”, “I had never heard of Quantiferon gold,
but because of the session, I read that in detail”,
and “I searched Pub Med to look for articles from
India which might be more relevant”. The session
stimulated “team building” with their peers. The
small group teaching was well accepted and found
to be more useful than lectures. Overall, there was a
favorable perception regarding vertical integration.
On discussion with the faculty, aspects of greater commitment in terms of time and resources,
and cooperation among faculty members were
highlighted. The faculty was motivated to read
in greater detail to clarify the students’ queries.
Feedback scores from the students were positive,
confirming the themes which emerged from the
focus group discussion. Tuberculosis is a major
public health problem in India and it is important
for students to have a deep understanding of the
topic (4). Case-based teaching on a disease of high
prevalence has been shown to improve application
of knowledge (5). Our study has highlighted that
such sessions help the students to form cross-links
and connections, resulting in a smoother transition
into clinical practice.