Vertical integration in the teaching of final year medical students

Dear Editor, The traditional approach to medical educationhas been dichotomous, with a lack ofintegration between basic sciences and clinicalmedicine (1). Recent reforms have called forindividualizing the learning process, integratingknowledge with practice, and cultivating a spiritof lifelong learning (2). Vertical integrationbreaks the traditional division between clinicaland pre-clinical sciences, resulting in betterunderstanding and application of concepts (3).We did an exercise to integrate basic sciencesand clinical medicine in the teaching of medicalstudents. After obtaining informed consentand ethical clearance, a group of final yearundergraduate students underwent verticallyintegrated, small group, problem-based trainingon tuberculosis. We studied the effect of theintegration on the students’ understanding of thesubject and acceptance of this method. Studentswere divided into intervention and control armsof 10 students each, based on the medical unitsin which they were posted. The control armunderwent standard clinical teaching (lecturesand practical sessions), as per the institutionaleducation policy. The intervention group wasgiven three case scenarios which highlightedthe various presentations of tuberculosis, withrelevant questions regarding the pathogenesis,clinical course, and management. These werediscussed in a multidisciplinary interactivesession, with input from the faculty taken fromthe departments of Pathology, Microbiology andInternal medicine. Triangulation of data frompre- and post-test scores, focus group discussionand feedback scores was done.When compared to the mean pre-test score,the mean post-test score in the interventiongroup significantly improved (6.7 vs. 12.44, meandifference: 5.74; 95% CI 2.71-8.95; p=0.003).There was a significant difference in the meanpost-test scores between the intervention andcontrol groups (12.44 vs 7.55, mean difference:4.89; 95% CI 3.89-5.84; p<0.001). On qualitativeassessment by focus group discussion, the studentsstressed on the usefulness of the session and feltthat vertical integration facilitated “integrationand application of knowledge”. They were able to“recognize how diverse processes are inter-related”.The problem-based approach motivated them to doself-directed learning and facilitated formulationof research ideas. In their own words, “The onusof the learning was in our hands, so we learntbetter”, “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 fromIndia which might be more relevant”. The sessionstimulated “team building” with their peers. Thesmall group teaching was well accepted and foundto be more useful than lectures. Overall, there was afavorable perception regarding vertical integration.On discussion with the faculty, aspects of greatercommitment in terms of time and resources,and cooperation among faculty members werehighlighted. The faculty was motivated to readin greater detail to clarify the students’ queries.Feedback scores from the students were positive,confirming the themes which emerged from thefocus group discussion. Tuberculosis is a majorpublic health problem in India and it is importantfor students to have a deep understanding of thetopic (4). Case-based teaching on a disease of highprevalence has been shown to improve applicationof knowledge (5). Our study has highlighted thatsuch sessions help the students to form cross-linksand connections, resulting in a smoother transitioninto clinical practice.