|Year : 2015 | Volume
| Issue : 4 | Page : 431-438
Introducing integrated teaching and comparison with traditional teaching in undergraduate medical curriculum: A pilot study
Mausumi Basu1, Palash Das2, Gagori Chowdhury3
1 Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
2 Department of Community Medicine, College of Medicine and Sagore Duta Hospital, Kolkata, West Bengal, India
3 Department of Bio-Informatics and Bio-Physics, University of Calcutta, Kolkata, West Bengal, India
|Date of Web Publication||14-Jul-2015|
Department of Community Medicine, IPGME&R and SSKM Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Medical colleges in India usually follow a traditional curriculum, characterized by "discipline wise model" which compelled Medical Council of India to recommend a teaching approach characterized by maximal efforts to encourage integrated teaching (IT) between traditional subject areas. Objectives: To assess the feasibility of IT; to compare IT with traditional teaching (TT) and to analyze the student's feedback and faculty feedback about perception of IT. Materials and Methods: An interventional study was conducted among fifth semester students using pre- and post-test questionnaire and student and faculty feedback forms. Students were divided randomly into two groups. IT was introduced to Group I on the topic of tuberculosis (TB) by faculties of different disciplines; using methods of didactic lectures, seminars, role play, clinical case presentation, demonstration of Ziehl-Neelsen stain, Bacillus Calmette-Guerin vaccination and visit to Directly Observed Treatment Centre. Group II were exposed to TT on TB by faculties of Community Medicine using method of didactic lectures. Paired and un-paired t-test and effect size were used as statistical tests. Results : Statistically significant results were obtained using pre- and post-test questionnaire of IT. Similarly, statistically significant results were obtained using posttest results of IT and TT. Effect size that is: Cohen's d and Pearson correlation revealed large effect which indicates high influence on student achievement. The students and faculty showed a positive attitude about IT. Conclusion: The introduction of IT was found to be feasible and to be more effective and acceptable than TT.
Keywords: Integrated teaching, student and faculty feedback form, traditional teaching
|How to cite this article:|
Basu M, Das P, Chowdhury G. Introducing integrated teaching and comparison with traditional teaching in undergraduate medical curriculum: A pilot study. Med J DY Patil Univ 2015;8:431-8
|How to cite this URL:|
Basu M, Das P, Chowdhury G. Introducing integrated teaching and comparison with traditional teaching in undergraduate medical curriculum: A pilot study. Med J DY Patil Univ [serial online] 2015 [cited 2020 Jul 4];8:431-8. Available from: http://www.mjdrdypu.org/text.asp?2015/8/4/431/160778
| Introduction|| |
There are many innovations and trends in medical education that have been undertaken globally which include self-directed learning, problem-based learning, integrated teaching (IT) and community orientation.  Integration of teaching is defined as the organization of teaching matter to interrelate or unify the subjects which are frequently taught in separate academic courses or departments.  It simply means bridging connections between academic knowledge and practicals. 
Integration can be done in the following ways: Horizontal integration means that two or more departments teaching concurrently merge their educational identities. Vertical integration is an integration between disciplines traditionally taught in the different phases of curriculum There are four major components in IT namely:
Medical education is related to the community services; so we need to teach our students to correlate the various subjects to create better doctors. Teaching different aspects of a topic by faculty members of relevant departments instead of one department will better assimilate the knowledge. Ultimately this will impart the basic knowledge of the topic for better understanding of the various aspects of the diseases which will create better doctors in society who will provide good health care services for community needs. Thus to improve effective diagnosis and better treatment of the patients and to improve the quality of student's learning, integrated learning is the need of an hour.
- Integration of experience,
- Social integration,
- Integration of knowledge,
- Integration as a curriculum design.  Harden described 11 steps of the integration ladder - A tool for planning, implementing and evaluating medical curriculum. 
As of February 6, 2014, there were 2372 recognized and operating medical schools in 179 countries or territories listed in the International Medical Education Directory; among these more than 300 are in India (Medindia) and 14 are in West Bengal. 
Medical colleges in India usually following a traditional curriculum, characterized by "discipline wise model" with a high degree of compartmentalization into subjects of basic sciences, preclinical, paraclinical and clinical branches; leads to unnecessary repetition and confusion in student's mind due to difference of opinion leading to improper grasping of the subject. This discourages students from learning, and they get disinterested in applying knowledge achieved into practice. Thus, Medical Council of India has been compelled to adopt a need based curriculum for undergraduate medical education in India. "Regulations on Graduate Medical Education, 1997" recommended a teaching approach characterized by maximal efforts to encourage IT between traditional subject areas using a problem-based learning approach and de-emphasize compartmentalization of disciplines so as to achieve both horizontal and vertical integration in different phases in order to provide the students with a holistic rather than fragmented learning perspectives. 
At present in our institution, the existing system of the undergraduate curriculum for MBBS is nonintegrated, discipline-based where teaching activity involves lecturing. Thus, this study was designed to introduce the method of both vertical and horizontal integration for undergraduate medical students for the first time in this college with the objectives of to assess the feasibility of application of IT; to compare IT with traditional teaching (TT) and to analyze the student's feedback and faculty feedback about perception of IT.
| Materials and Methods|| |
Study design and setting
An institution-based intervention study was carried out at a Government Tertiary Care Teaching Institute of Kolkata, West Bengal, India under West Bengal Health University. The undergraduate MBBS first batch was admitted in 2004 and graduated in 2009. As mentioned, this medical school offers a nonintegrated, discipline-based curriculum where teaching activity involves didactic lecturing. Study period was from April 2012 to February 2013. Study population was comprised of all fifth semester undergraduate medical students, aged 21-24 years, both sexes, studying in the same medical college. Sample size was 100 and sampling technique followed was simple random sampling.
The study tools were predesigned pretested structured self-administered questionnaire containing both open ended and close ended questions; student feedback forms and faculty feedback forms. The self-administered questionnaire consisted of 22 questions; among those, 19 were multiple choice question (MCQ) type and 3 were open questions; each carried 1 mark; thus the total possible scores in the test was 22. The study tools were developed in consultation with 3 experienced teaching staffs, 1 each from 3 disciplines : n0 amely Community Medicine, Microbiology and Pharmacology. It was pretested among 30 senior students. Necessary correction and modification were adopted before final data collection.
Data collection technique
Prior to the study, clearance was obtained from the Institutional Ethical Committee. Interested teaching staffs from various departments were approached, and a meeting was organized during which the concept of IT was discussed. Foundation for Advancement of International Medical Education and Research (FAIMER) trained staffs experienced in the IT methodology were invited to conduct a faculty development workshop. A 1 day workshop was conducted for 4 h. At the end of the workshop, an interactive session with teaching staffs from all concerned subjects with a moderator was conducted. The topic (tuberculosis [TB]) was selected; desired learning outcomes finalized; drafting of the timetable done; and then the concerned departmental staffs were involved. The subtopics were epidemiology, pathophysiology, clinical presentation, laboratory investigations, management of cases, prevention by vaccination, Revised National Tuberculosis Control Program (RNTCP) and pediatric TB.
One hundred students of fifth semester batch were randomized to be included in the two groups for IT and TT respectively.
Written informed consent with explanation that the internal assessment marks will not be affected (which means this posttest would not include in the internal assessment) was taken from each student participant. IT was introduced to Group I (n = 50). TB as a topic was implemented by the active involvement of Departments of Community Medicine, Pathology, Radiology, Microbiology, Pharmacology, Chest Medicine, General Medicine and Pediatric Medicine. The lesson headlines/titles on which teaching-learning sessions conducted were epidemiology, pathophysiology, clinical presentations, laboratory investigations, management of cases, vaccination, RNTCP and pediatric TB. They followed the timetable (schedule) for 5 weeks (1 day/week; each Monday; 2-4 pm; total 5 × 2 = 10 h) on the above sub topics. All those major points about TB were covered by didactic lectures, group seminars, role play, clinical case presentation, demonstration of Ziehl-Neelsen stain, Bacillus Calmette-Guerin (BCG) vaccination, visit to Directly Observed Treatment (DOT) center. Group seminars were conducted on 5 th day; students were divided into five groups; each group had 10 members; sub topic of TB given to them (such as problem of TB in India, RNTCP, diagnosis, treatment, BCG vaccination allotted to Group 1, 2, 3, 4, 5 respectively); they presented by power point (10 slides; 7 lines in each slide); total 10 min were allotted for each group (6 min for presentation and 4 min for question-answer session) × five groups = total 50 min; teachers of Community Medicine, General Medicine, Pediatric Medicine, Chest and TB, Pathology, Pharmacology, Microbiology, Radiology were present. For role playing; both students and teachers participated; 10 min for each role play × 5 role plays; total 50 min (themes were IEC, multi-drug resistance-TB, TB-HIV/AIDS, chemoprophylaxis and DOT allotted to group 1, 2, 3, 4, 5, respectively). Group seminars were most useful in our study; because the process of teaching was interactive and better correlation was there. All 50 students were present for 5 days (a copy of timetable included as an Appendix 1). Before the start of the session, students were given a pretest questionnaire containing 22 Questions; 19 MCQs and three open questions and at the end of session a posttest questionnaire with same set of questions were introduced to them. Each question had one mark; thus the total possible score in the test was 22.
Group II (n = 50) had conventional way of teaching on the same topic by faculties of Community Medicine through didactic lectures for 5 days (1 day/week; each Wednesday; 2-4 pm; total 5 × 2 = 10 h). To compare with IT, TT also had same sub-topics such as pathophysiology, clinical presentation and laboratory investigations, etc. covered by teachers of Community Medicine. In the TT, the teachers of Community Medicine imparted teaching on TB for a total of 10 h. Out of 50 students, 46 were present for those 5 days. The same pretest questionnaire was given before their first lecture class, and a posttest questionnaire with the same set of questions was introduced after the completion of the topic. Group II which had traditional lectures was assured to be exposed to IT method subsequently.
Response to feedback questionnaire forms were obtained from students' and teachers' to find their level of satisfaction and to evaluate their response with respect to activities related to implementation as well as to analyze merits and demerits of IT.
The following points clarify the differences between IT and TT:
The data were analyzed by proper statistical tests. Comparison of marks of pre- and post-test questionnaire of the IT group and TT group was done by paired t-test.
Comparison of marks of pre- and post-test results of both groups was done by un-paired t-test. P value from 0.01 to 0.05 was considered to be statistically significant; from 0.001 to 0.01 was considered to be statistically very significant; from 0.0001 to 0.001 was considered to be statistically extremely significant; and <0.0001 was considered to be statistically extremely significant (GraphPad Statistics Guide; http://graphpad.com/guides/prism/6/statistics/index.htm?extremely_significant_results.htm). Comparison of the posttest results of both the groups would enable the investigator to compare the performances of both the groups and to select which one is a better method of teaching. In addition effect size  Cohen's d and Pearson r were also calculated.
In addition, faculty feedback and student feedback analysis done and expressed by percentage and Pie diagram whereas student feedback questionnaire analysis done and expressed as item total statistics.
The analysis was done in Microsoft Excel 2010 (Microsoft Corp., Redmond, WA, USA), Epi-info 6.04d (Centers for Disease Control and Prevention, Atlanta, GA, USA, 2001) and Statistical Package for the Social Sciences SPSS Inc. Released 2007. SPSS for Windows, Version 16.0. (Chicago, IL,USA).
Cohen defined an effect size as "the degree to which the phenomenon is present in the population' or "the degree to which the null hypothesis is false" (1988). Although there are several effect size indices, the most commonly used of these indices is d (Cohen, 1988) which reflects the difference between two group means divided by their pooled within-group standard deviation. Cohen suggested that d = 0.2 be considered a "small" effect size, 0.5 represents a "medium" effect size and 0.8 a "large" effect size.
A few authors (Bobko, 1995) have suggested that researchers should report a correlation coefficient as a measure of effect size. Alleged advantages of r are that it is a more familiar statistical value than d and that it is a bounded index (d has no fixed range) which may make interpretation easier. Cohen provided rules of thumb for interpreting these effect sizes, suggesting that an r (Pearson correlation coefficient) of ǀ.1ǀ represents a "small" effect size, ǀ.3ǀ represents a "medium" effect size and ǀ.5ǀ represents a "large" effect size. 
Item total statistics
An item-total correlation test is performed to check if any item in the set of tests is inconsistent with the averaged behavior of the others, and thus can be discarded. The analysis is performed to purify the measure by eliminating "garbage" items prior to determining the factors that represent the construct;  that is, the meaning of the averaged measure. A small item-correlation provides empirical evidence that the item is not measuring the same construct measured by the other items included. A correlation value <0.2 or 0.3 indicates that the corresponding item does not correlate very well with the scale overall and thus, it may be dropped. 
| Results|| |
The total number of students registered in fifth semester were 100. Their age ranged from 21 to 24 years; with mean age was 22.6 years; most of the students (63%) were in the age group of 21-22 years and 67% were males.
Statistically extremely significant results were obtained using pre- and post-test questionnaire of IT (P < 0.0001). Similarly, statistically extremely significant results were obtained using posttest questionnaire of IT and TT (P < 0.0001); whereas statistically significant results were obtained using pre- and post-test results of TT (P < 0.05) and no statistically significant results were obtained using pretest questionnaire of IT and TT (P > 0.05).
[Table 1] reveals comparison between pre-and post-test scores of both IT and TT.
It showed mean, standard deviation, standard error and variance values of the total marks obtained in the pre- and post-IT for Group I using Student's paired t-test. The total possible score in the test was 22. The total marks obtained in the posttest were significantly higher in IT study group (Group I) than pretest marks of the same group (Group I). Highly significant results were obtained on statistical comparison (P < 0.0001). By conventional criteria, this difference is considered to be extremely statistically significant.
This table also depicted mean, standard deviation, standard error and variance values of the total marks obtained in the pre- and post-TT for Group II using Student's paired t-test. The total marks obtained in the posttest were significantly higher in TT study group (Group II) than pretest marks of the same group (Group II). Significant results were obtained on statistical comparison (P < 0.05). By conventional criteria, this difference is considered to be statistically significant.
Regarding effect size interpretation; IT group had large effect size which indicated that IT had a high influence on student achievement, and TT group had Medium effect size indicated that TT had medium influence on student achievement.
[Table 2] reveals comparison of improvement of scores between IT and TT using pre-and post-test scores.
It depicted mean, standard deviation, standard error and variance values of the total marks obtained in the test conducted pre-IT and pre-TT and also post-IT and post-TT for both study groups (Group I and II) and the inter-group comparison of significance using Student's un-paired t-test. The total marks obtained in the pretest were not significantly higher in IT study group (Group I) than the traditional method study group (Group II) indicating randomization was proper; so the scores were near each other. No statistically significant results were obtained using pretest questionnaire of IT and TT (P > 0.05). By conventional criteria, this difference is considered to be not statistically significant. The total marks obtained in the posttest were significantly higher in IT study group (Group I) than the traditional method study group (Group II). Highly significant results were obtained on statistical comparison (P < 0.0001). By conventional criteria, this difference is considered to be extremely statistically significant. Regarding effect size interpretation; in pretest scores IT group had Small effect size than TT group indicating small influence on student achievement while in posttest scores IT group had Large effect size than TT group indicated that IT had High influence on student achievement.
[Table 3] shows the student's feedback about IT: The maximum possible score for each item in the feedback questionnaire was 5. The average student ratings across the items varied between 3.7 and 4.1. Average correlation between items was 0.647; Cronbach's alpha of the feedback tool was 0.907 which was high indicating that internal construct reliability was met. Corrected total item correlation indicates that all items contributed to the construct of student's perception on IT.
|Table 3: Student feedback questionnaire analysis – Item total statistics|
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Overall rating by students about IT [Figure 1]: More than two third of students expressed their view that this new method was very good; 16% told that it was excellent followed by 10% as good. However, nobody gave any negative feedback about IT methodology.
|Figure 1: Overall rating by students and teachers about integrated teaching|
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Faculty's feedback about IT [Figure 1]: Sixty percent of faculties were agreeable to this new integrated method of teaching as very useful and 20% told that it was useful; however 10% felt that it was not useful because it was time consuming with syllabus burden.
| Discussion|| |
The ultimate objective of medical education in this era is to bring new perspectives on content, process, extent and evaluation of the medical curriculum. Integrated modular system has been recently evolved as an important strategy which aims to bring coordination in teaching-learning activities. 
In recent years, throughout the world such integrated curricula have been used by faculties to teach the students. ,,,,, Medical educationists realized that there is a need for integrating basic and clinical medical sciences  and an integrated approach with strong clinical relevance captures students attention and creates more excitement in learning.  The students trained with such an integrated curriculum, make more accurate diagnosis than did students trained in a conventional curriculum. 
The hierarchy of teaching and learning activities in terms of their educational effectiveness comprise Level 1, interactive and clinically IT and learning activities; Level 2(a), interactive but classroom-based teaching and learning activities; Level 2(b), didactic but clinically IT and learning activities; and Level 3, didactic, classroom or standalone teaching and learning activities. 
The present study was an attempt to improve the quality of medical education with the innovative curricular strategy to teach TB in an integrated manner which revealed that IT was better than TT ; the results of which was similar to some other previous studies. ,,,,,
Similar studies at Seth GS Medical College, Mumbai, Maharasthra by Joglekar et al.;  at MGM's Medical College, Navi Mumbai, India by Kate et al.;  at Pramukhswami Medical College, Karamsad, Gujarat by Ghosh and Pandya;  at Jawaharlal Nehru Medical College, Belgaum Karnataka by Dandannavar  and at Terna Medical College, Nerul, Navi Mumbai by Nikam and Chopade.  revealed that the marks obtained by the students who had undergone IT was statistically significantly greater than those who did not.
In another study, which was done in Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER) Pondicherry by Soudarssanane and Sahai et al.;  the IT of epidemiology included incorporation of presentation of actual epidemiological studies, which were conducted in the local population along with the discussion of theory points there off with the involvement of the clinical teaching departments, was a novel attempt in the subject. This method was also well appreciated by their students.
However in a study by Kadam and Sane at Rajiv Gandhi Medical College, Kalwa, Thane, Maharashtra  the statistical comparison between the evaluation after integrated and traditional lectures had not shown significant impact of integrated lectures.
In our study, the students felt a positive attitude of IT; they told that it had enhanced the student's understanding of the topic, they recognized that integrating the medical subjects was useful and of interest to them, and that it should be continued; they felt that there was a positive interaction which helped them to correlate the pre- and para-clinical and the clinical subjects; which was similar to studies by Dandannavar at Karnataka,  Nikam and Chopade at Mumbai,  Soudarssanane and Sahai at JIPMER,  Kadam and Sane at Maharashtra,  Kumari et al. at Bangalore,  Mahajan et al. at Ahmedabad  and Rehman et al. at Pakistan. 
In the present study, IT was perceived to be very good by a majority of the students with regards to an improvement in the appreciation and application of basic science knowledge; in the student's feedback questionnaire the Cronbach's alpha was 0.90; average student ratings across the items varied between 3.7 and 184.108.40.206%. A similar finding was noted by Kumari et al.,  Vyas et al.  and Musal et al. 
Our study results indicate that interest in integration of the curriculum was high among faculty members; 60% told that that it is very useful and another 20% told that it is useful; that individual faculty members were interested in increased integration, but that the current level of integration was not adequate; other previous studies also addressed this topic. ,,,,,
The findings and the experience of this study supports the view of other studies that such newer methods of education help to increase teacher-student and teacher-teacher interactions and that IT method avoids fragmented manner of teaching where teachers are not aware of what is taught in other subjects. It also removes subject phobia and develops interest in the topic.
| Limitations|| |
- The students of Group II were not exposed to faculties of other disciplines. The pathophysiology, clinical presentation and laboratory investigations, etc. covered by Community Medicine. Thus, there was an element of bias.
- In traditional compartmentalized teaching, the relevant subtopics of TB are.
- Taught by faculties of different subject specialties at different times in course of UG curriculum.
- Feedback was taken only for IT.
- The intervention in the IT group involved not only IT, but also different teaching methods such as role play, seminar, and clinical case presentation and so on. The TT group only had noninteractive didactic lectures. So it was not sure that the difference in postintervention scores was because of IT or because of the various teaching methods employed. It is, therefore, the package as a whole that is being assessed in the present study.
| Conclusions|| |
- The study showed that it is possible to adopt an integrated learning methodology in medical teaching under a conventional curriculum in spite of all the challenges;
- The IT was found to be more effective than the traditional one. Significant results were obtained by comparing integrated with the traditional method;
- This method was well accepted by students as well as faculties. Both faculties and students had a positive attitude toward this teaching innovation;
- Thus, time has come to introduction of IT over TT;
- Future action plans:
- Group II which had TT would be introduced to IT.
- Continue IT in other topics and other disciplines.
| Recommendations|| |
- Students' enthusiasm and motivation have to be kept alive for permanent implementation of IT method;
- Considering the volume load which the students are subjected to, IT can definitely save their time and energy, and give them better insight into the subject.
| Acknowledgment|| |
We are very thankful to faculties and fellows of FAIMER, PSG-FRI for their constant support and encouragement.
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[Table 1], [Table 2], [Table 3]