Integration of Basic Sciences and Clinical Sciences in a Clerkship:
A Pilot Study

INTRODUCTION
The need for a strong scientific underpinning for medical education was envisioned in the late nineteenth century, leading to the Flexnerian revolution, recognized as the single major reform of medical curricula of the twentieth century.¹ The goal, to translate the evolving body of scientific knowledge into clinical practice, is even more significant today than it was in 1910 when the report was first published. The Flexner report resulted in the now familiar “two plus two” curricula in the U.S. medical schools, with the basic sciences taught during the first two years followed by the major or “core” clinical clerkships in the third and fourth years. This curricular formula has since been modified by most schools without significant deviation from the Flexnerian principles in an added effort to create vertical and horizontal integrations. This was initiated by the reorganization of teaching into an organ system-based program by the Case Western Reserve University School of Medicine in 1952.¹ The present medical school curricula in the United States reflect variations on this theme with many medical schools having additionally incorporated innovative learning experiences and teaching methodologies.

The medical curriculum at the University of California Davis (UCD) is structured with the first two years taught largely by faculty on site at the School of Medicine on the Davis campus, and the last two twenty miles away on the wards and in the clinics at the UCD Medical Center on the Sacramento campus or at affiliated sites. Because of the geographic split between the two campuses, accessibility to basic scientists has been limited for third and fourth year students. In the absence of a structured basic science unit incorporated into the third or fourth year clerkships, there is very little opportunity for students to continue to explore basic science issues relevant to clinical problems in a formal way other than by department-sponsored lectures that contain variable amount of basic science materials. Although the basic science departments offer electives, the numbers of students who take these tend to be few since most of these courses are devoid of clinical content and divorced from the day-to-day clinical activities during the third and the fourth years of medical education.

The present study was designed to provide a model for a systematic mechanism for medical students in their fourth year of education to explore, research and strengthen their knowledge base of basic science issues relevant to commonly encountered clinical problems. The study was based on a hypothesis that a systematic and structured exploration of the basic sciences during the clinical years of medical education will sustain student motivation for life-long learning of the scientific basis of medicine as a part of patient care. To accomplish this, a clinician (Dr. John Sakles/JS, Director of Student Programs in the Division of Emergency Medicine and instructor for the required fourth year Emergency Medicine clerkship), and a basic scientist (Dr. Vijaya Kumari/VK, a neurobiologist with a medical degree, in the Department of Cell Biology and Human Anatomy, with main teaching responsibilities in the first year) collaborated to develop a model of an integrated curriculum. A case-based approach was selected since it was considered to be most effective at this stage of the students’ training. The basic principles of the study design included: building on prior knowledge, enhancing active learning, and promoting critical thinking and problem-solving skills. We presumed that this model, if successful, could be incorporated more broadly into other clerkships at our school, and in other schools, to create a systematic and structured link between the basic and clinical sciences beyond the preclinical period of undergraduate medical education.

The Emergency Medicine clerkship during the fourth year provided a unique opportunity to achieve our goals for several reasons. At UCD, Emergency Medicine is a division of the Department of Internal Medicine and has strong academic leadership. At the time of this study, the four week long clerkship in Emergency Medicine was a requirement for all fourth year students, a situation that is paralleled in approximately 20% of all U.S. medical schools. Students in the clerkship have had the opportunity to build a sound knowledge base and clinical skills in Medicine, Surgery, Pediatrics and Primary Care during the third year clerkships. The Emergency Medicine clerkship provides clinical experience that allows medical students the opportunity to apply their knowledge in a wide variety of clinical areas. The clerkship also incorporates “hands on” laboratory sessions including airway management, suturing, and advanced cardiopulmonary resuscitation. Students are also required to participate in problem-based topic discussion sessions using clinical cases to develop a knowledge base fundamental to the management of patients seen in the Emergency Department. We anticipated that the clerkship would allow the identification and selection of cases that have rich basic science underpinnings so that the integration would be more realistic and relevant to their ongoing patient care.

One year prior to the full-length study, we carried out a pilot project using one group of seven fourth year students. We used a split-session format with an interval of three to seven days between two sessions. Students were familiar with this teaching method that they had experienced sporadically during the first year of medical school. A case was presented “cold” during the first session to lead to the identification of the most relevant clinical and basic science issues for exploration. During the second session, students shared with the group the information that they had researched, and integrated it with the clinical manifestations, pathophysiology and management of the patient. The pilot study received a strong positive response from the students for its effectiveness in integrating basic and clinical sciences, with 7/7 supporting the incorporation of the model in all fourth year clerkships. Six out of seven students rated the educational value of the sessions as excellent (5, on a Likert scale of 1-5) or very good (4). Thoughtful student comments included the suggestion to choose cases with broad learning potential, to incorporate discussion of molecular biology issues, and to use real cases with images, laboratory data and details of management. Based on these preliminary results, the full-fledged study was begun approximately one year later.

MATERIALS AND METHODS
Study Setting and Participants
The study group consisted of 58 fourth year medical students taking the required four-week clinical rotation in Emergency Medicine at the University of California Davis, School of Medicine. Ten four-week sessions of the clerkship were offered from July to May 1999, with 8 to 15 students per session. Participants were UC Davis medical students and visiting fourth year medical students from other American schools. The UC Davis medical students selected the dates for the Emergency Medicine rotation through a lottery system. Students considering Emergency Medicine as their chosen specialty typically take this rotation early in the academic year, from July through December.

Study Design
The integrated teaching approach required collaborative teaching by a clinician and a basic scientist who was an expert in the field relevant to the clinical case. JS served as the clinician consultant for this study, assisted in some instances by a second clinician chosen from the field represented by the case. VK played a key role in identifying and recruiting the basic science faculty, in addition to serving as the basic science expert for one of the cases. A staff member (Renee Maldonado/RM) assigned to the clerkship was responsible for the logistics. Basic science faculty who volunteered to teach were all basic scientists with PhD degrees. All were supportive and enthusiastic of the integrated approach and understood their roles as experts. It was explained beforehand to the faculty that their role was to facilitate the discussion, prompt questioning, serve as a resource, and ensure that the clinical and the basic science information were integrated in the context of the patient problem. The new integrated teaching/learning session occupied one and one-half to two hours per week for two weeks of the rotation. This was in addition to usual the didactic lectures and laboratories. During orientation for the Emergency Medicine rotation, JS presented an overview of the learning objectives and format of the integrated teaching approach.

Based on the pilot study, we elected to use a split session format and to incorporate some of the principles of problem-based learning. The case was presented “cold” during the first session, with images of the physical findings and laboratory data. The most relevant clinical and basic science

issues were then identified by the students for exploration. Midway through the study, it was apparent from informal student feedback that the split session format was inefficient for fourth year students and that the same goals could be accomplished in a single session with prior preparation. The format was modified accordingly by providing the cases ahead of time, assigning specific questions to small subgroups of students, and facilitating active discussion of the issues by the group. Since different groups of students took the split session format and the single session format, it was not possible for us to provide accurate comparison of the two methodologies. Since the major goals of the study remained unchanged, the data derived from both groups (using the same evaluation instrument) were pooled for the final analysis.

Although we expected the cases to be selected by the students, practical issues such as limitation of time prevented them from doing this. Therefore, JS selected commonly seen patient cases in the Emergency department with easily identifiable basic science issues: stroke, diabetic ketoacidosis and sickle cell crisis and myasthenia gravis. The basic science facilitator was either a basic scientist who taught the relevant material or a clinician with research expertise in the disease. On occasions, a clinician expert who could discuss the principles of management was added to the group. Table 1 lists four cases used in the study, the disciplines of the basic scientists/clinicians who facilitated them, and some of the basic science principles discussed in each case.

For each case, the facilitator/s made sure that the basic science issues covered patient manifestations and disease management. Largely, the topics came up during the discussion through questions that the students raised or information that a student would share with the group. If an important basic science principle was not brought up, the facilitator/s would pose questions related to it to initiate a discussion. Because of time constraints, not all basic science principles could be included in the discussions of each case.

The study was approved by our Institutional Review Board (IRB) and granted waiver of informed consent.

Survey Content and Administration
A survey instrument was designed to determine the degree to which the short-term educational goals of the integrated teaching approach were achieved. It was distributed to the students at the final session and collected in an anonymous fashion. The six questions used in the instrument are included under Results in Table 2 (questions 1-4) and Table 3 (question 5).

RESULTS
The responses to the five questions included in the evaluation questionnaire are presented in Tables 2 and 3. In some instances, answers were missing from the evaluation as reflected by . The results showed that ninety-seven percent of the participants felt that the integrated sessions enabled them to achieve a deeper understanding of the basic science principles relevant to the clinical cases they reviewed (Table 2, question 1). Eighty-six percent agreed that the sessions improved their ability to evaluate and manage another like patient case (Table 2, question 2). Asked if more experiences like this would enhance their motivation for exploring basic science principles relevant to clinical problems, 69 percent of the participants agreed that it would (Table 2, question 3).

As seen in Table 2 (question 4), 95 percent of the participants felt that understanding basic science principles relevant to clinical problems would contribute to better patient care. The results also revealed that 79 percent of the respondents would recommend the integrated teaching in other fourth year clerkships (question 5, Table 3).

We asked two additional questions to determine whether or not the short-term goals of the study were met by the design of the learning experience. These goals were explicitly stated at the beginning of each session and also included in the survey instrument. The two questions inquired about the roles of small group collaborative learning approach and the availability of a basic science expert in meeting the goals of the study. Eighty-two percent of the respondents agreed that collaborative learning in a small group helped to achieve the short-term goals of the study. Twelve percent of the respondents were undecided and 6 percent disagreed that the model promoted collaborative learning. With respect to the presence of a basic scientist to facilitate discussion, 86 percent of the respondents agreed that the availability of a basic science expert enabled them to meet the short-term goals of the study.

We did not formally survey the small number of basic scientists and clinician consultants who volunteered to participate. Comments provided at the end of the sessions indicated their full support of the study goals and methodology. The basic scientists were enthusiastic that the study allowed them to teach students in their fourth year of medical school, with a focus on select the basic science principles raised in the context of a patient problem.

DISCUSSION

One of the drawbacks of the current medical school curricula is the lack of continued formal integration of the basic sciences with the clinical sciences through all four years of the undergraduate education. It has been pointed out that if the importance of basic science objectives is accepted, these objectives should be achieved early in training, maintained at exit from medical school, and revisited in continuing medical education.² At this time, most schools are far from achieving an ideal blend of the basic and clinical sciences during undergraduate medical training, not to mention at levels beyond it.

A review of the approaches adopted by eight schools that participated in a Robert Wood Johnson Foundation project serves to illustrate some of the methods used to integrate basic sciences with clinical sciences.³ The study found that bringing clinical relevance to basic sciences has been achieved far better than reinforcing basic science in the clinical years.³ Examples of the former include: the use of a problem-based learning (PBL) format; lectures complemented with small-group, case-based learning; aligning certain basic science subjects such as anatomy with courses in physical diagnosis and Objective Structured Clinical Examinations (OSCEs); co-teaching by basic science and clinical faculty; and, early exposure to and experience with real patients. In contrast to the reasonable degree of success achieved in bringing clinical relevance to the basic sciences, schools encountered far greater challenges when incorporating basic sciences into clinical curricula. In general, these attempts occurred on a small scale and tended to involve supplementing traditional clerkships with PBL sessions or a seminar series designed to focus on basic science issues. Attempts to include basic scientists in ward rounds were not successful for logistical or political reasons.³

Our study comes closest to the curricular models that have incorporated PBL in the clinical years. A 1997 review of

PBL in the clinical setting found very few that met the criteria outlined in Barrow’s taxonomy of PBL.⁴ However, more recent publications suggest that PBL is gaining a greater presence in the third year.^5-7 The most impressive is the Manchester experience ^8,9 that designed cases to trigger basic science objectives, matched faculty- and student-generated objectives, and showed that the students’ knowledge of basic sciences increases in their third and fourth years. The results of our pilot study suggest that it is possible to provide an opportunity for a systematic review of the basic sciences during the fourth year by placing it within the context of clinical problems in a required clerkship. Emergency medicine rotation provided an ideal avenue to develop a prototype for this integration since students see an entirety of undifferentiated population of patients with a wide variety of pathophysiologic processes. For example, as in our experience, a patient with sickle cell crisis provided a leading point to the discussion of the molecular abnormalities of hemoglobin and potential therapy targeted at the specific abnormality. This type of review could be critical to the development of life-long learners who need to continue to explore the scientific basis of new ideas on the pathophysiology and management of diseases.

In our study, a high percentage of students felt that the integrated model enabled them to achieve a deeper understanding of basic science principles relevant to clinical problems. The majority of students also reported that they believed that the sessions would improve their ability to manage similar patients in the future. Two-thirds of the students indicated that this learning approach would motivate them to explore basic science principles in future, suggesting that it would be effective in supporting the concept of life-long learning. The presence of the basic science experts was valued and appreciated by the fourth year students who generally have little contact with them beyond the second year.

There are several drawbacks to our study that can be rectified if a full-blown model were to be instituted in the future. Although we were able to provide a model of integration in a month-long fourth year clerkship, this was not supported by other comparable efforts during the fourth year. Any discussion of “paper” cases in the clinical years is often criticized since it competes with the clinical experience and takes the student away from the main “teacher” during the clinical years, i.e., the patient. Although large time blocks spent away from the patient will compromise the clinical rotations, supplementing or replacing some of the didactic lectures with integrated case discussions might be a viable alternative. A better approach will be to motivate the students to focus the sessions on patients they have seen on the wards or in the clinics, thus providing a more meaningful role for the patient, the “teacher” in the learning process. In our study, we were not successful in motivating the students to bring cases that they helped manage in the Emergency Department to the discussion table. Although this appeared to be due to time constraints in a busy rotation with a more pragmatic (?how?? and “what??) than theoretical (?why??) emphasis, the disconnect between the real patient and the learning sessions is likely to have detracted from the benefits of this model.

Problem-based learning need not be the sole teaching method for bringing basic sciences back to the clinical years, as attested by the Rochester Double Helix Curriculum that incorporates an Advanced Basic Science block in each of the third year inpatient clerkships.¹⁰ Multiple learning formats are used to review the basic disease mechanisms at the cellular or sub-cellular level using journal clubs, laboratories, lectures, pathology case reviews, human simulator exercise, PBLs, and student presentations based on patients seen during the rotation. The immersion nature of this experience provides visibility to basic sciences in the clinical years and underscores its value in the education of the physician-in-training.

CONCLUSIONS

Our study suggests that it is possible to provide a structured basic science inquiry, in the context of a patient problem, using the principles of PBL, and aided by the presence of an expert basic scientist, in the fourth year of medical school. A greater emphasis on the basic sciences in the third and fourth years would sustain the relevance and value of subjects often relegated to the first and second year, with a “must get through” attitude on the parts of the students and the clinical faculty. The utility of basic sciences is to provide the theoretical framework for understanding why physicians practice the way they do.³ Approaches like ours are likely to encourage continued exploration of the scientific basis of clinical practice beyond medical training.

ACKNOWLEDGEMENTS

This study was supported by funds from the Office of the Dean, University of California, Davis, School of Medicine, and by the Harvard-Macy Institute, Physician-Educator Program. The authors thank Dr. Faith Fitzgerald, Professor of Internal Medicine, for her careful and constructive review of the manuscript. We are grateful to William Harley for his valuable assistance with the preparation of the tables.

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