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Diagnostic radiology in an integrated curriculum: Evaluation of student appraisal
International Commentary
Diagnostic Radiology in an Integrated Curriculum: Evaluation of Student Appraisal 1 Leif Ekelund, MD, PhD, M a r g a r e t Elzubeir, PhD
Rationale and Objectives. This study determined student perceptions of the effectiveness of an integrated radiology curriculum in a 6-year undergraduate medical school program. Materials and Methods. Student perceptions of the effectiveness of an integrated radiology curriculum were assessed with
a self-administered questionnaire that was developed in house and consisted of Likert-type and open-ended items. The questionnaire was distributed to 1997-1998 and 1998-1999 cohorts of 2nd- to 6th-year medical students. Quantitative data were analyzed by using descriptive statistics. Results. Ninety-nine of 173 students (57% response) returned completed questionnaires. Overall, students perceived inte-
grated radiology teaching as satisfactorily achieved and useful in facilitating learning. Compared with students in the 2nd and final years of undergraduate medical education and training, those in years 3-5 considered integrated radiology teaching to be very effective. Results of the survey suggest future modifications to improve the effectiveness of integrated radiology teaching. Conclusion. Radiology can be successfully integrated into modern medical curricula. Student comments indicate the need to structure and organize the integrated teaching better and to introduce it earlier in the medical school curriculum.
Key Words. Education, radiology and radiologists.
During the past decade many traditional medical schools have introduced integrated, problem-based programs (1-4). I/deed, the General Medical Council (5) strongly encourages "true integration of the course, both horizontal and vertical, using the term in the sense of interdisciplinary synthesis and not simply co-ordination or synchronization of departmentally based components." True integration therefore requires a recombination and coordination of previously segregated parts of the curriculum to provide unity and encourage students to adopt a holistic approach to clinical problems. Consequently, some medical schools have restructured their entire curricula to improve both horizontal (intersubject) and vertical (basic-clinical) integration.
Acad Radiol 2000; 7:965-970
From the Department of D~agnostic RadLology,PO Box 17666 (L.E.) and the Department of Medical Education (M.E.), Faculty of Medicine and Health ScFences, United Arab Emlrates University, AI Ain, United Arab Emirates ReceivedApril 26, 2000; revision requested June 7; revision received and acceptedJune 28. Address correspondence to L.E. ©AUR, 2000
In 1997 we published a description of our experiences of integrating diagnostic radiology in the medical curriculum of the Faculty of Medicine and Health Sciences, United Arab Emirates University (6). Although the benefits of problem-based, integrated teaching and learning in medicine are well documented (7-11)and there are many proponents of these educational strategies among our own faculty members and students, we still do not understand how effectively they are being applied. Indeed, given the energy and effort normally invested in the implementation of innovative curricula, evaluation of outcomes from the perspective of medical students is increasingly important to medical educators. In particular, questions are legitimately raised about whether changes in the curriculum are effective and worthy of broader application (12,13). Radiology plays an increasingly important role in modem medicine. According to available data, however, less than 1% of medical education budgets are devoted to radiology education during undergraduate training (14). The total length of undergraduate medical education varies from
965
F.M.H.S.
CURRICULUM
UNIVERSITY GENERAL REQUIREMENTS UNIT
2
PREPARATORY COURSE
INTRODUCTION TO MEDICINE ENGLISH, MEDICAL COMMUNICATION AND STUDY SKILLS CHEMICAL SCIENCES BIOLOGICAL SCIENCES i BIOLOGICAL SCIENCES 2 BIOMEDICAL SCIENCES ENGLISH, MEDICAL COMMUNICATION AND STUDY SKILLS CLINICAL COMMUNICATION HUMAN SCIENCES DEVELOPMENTAL SCIENCES PATHOBIOIA:~ICAL SCIENCES
3
HAEMATOLOGY AND IMMUNOLOGY ALIMENT2uRY SYSTEM CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM MUSCULOSKELETAL AND PERIPHERAL NERVOUS SYSTEM
4
UROGENITAL AND REPRODUCTION SYSTEM ENDOCRINE AND MEWABOLISH NEUROSCIENCES AND SPECIAL SENSES BEHAVIOURAL SCIENCES
5
JUNIOR CLINICAL ROTATION Medicine Paediatrics Surgery Family Medicine SPECIALITY ROTATION I Obstetrics / Gynaeeology I Psychiatry / Nenroseienees Medical Specialities Surgical Specialities Elective
6
7
MATHEMATICS & COMPUTING FOR SCIENCES - I, II ARABIC - I, II ENGLISH - I, If, Ill EMIRATES SOCIETY ISLAMIC THOUGHT
CLINICAL SCIENCES COURSE YEAR 2
SPECIALTY ROTATION II Obstetrics / Gynaecology 2 Emergency & Critical Care Medicine Community Medicine SENIOR CLINICAL ROTATION Medicine Paediatrics Surgery Family Medicine
8 Figure
1. Curriculum of the Faculty of Medicine and Health Sciences.
220 to 300 weeks, b u t o n l y 1 - 4 w e e k s are usually d e v o t e d to radiology. A t t h e F a c u l t y o f M e d i c i n e a n d H e a l t h S c i e n c e s o f the U n i t e d A r a b E m i r a t e s U n i v e r s i t y , w e h a v e i n t e g r a t e d r a d i o l o g y t e a c h i n g into the c u r r i c u l u m so that it is p r e s e n t e d
966
during all phases of undergraduate teaching (6). This article describes our experiences with this integrated radiology curriculum and the results of a medical student survey conducted to evaluate its effectiveness.
MATERIALS AND METHODS Students in our program are United Arab Emirates nationals for whom English is a second language, and their secondary school backgrounds often foster rote learning and memorization of information. Our faculty members are mainly of expatriate Arab, North American, European, and Asian origins. Radiology is represented in all phases of undergraduate teaching, in all organ system modules as well as clinical clerkships (Fig 1). We also participate in multidisciplinary seminars, which are included in organ systems years 1 and 2 (Fig 1). In these seminars the students present a typical case, including relevant radiologic investigations, and the tutors are available as resource persons. These sessions are a good example of problem-based learning. They usually last for 2 hours, with a general discussion toward the end of the session. Radiology is also actively involved in the various clinical clerkships (years 5 and 6 in the curriculum). The subject is presented in small-group seminars and in clinical conferences. In the group seminars, the radiology of various disorders is discussed with a problem-based orientati0n; the topic is appropriate to the student rotation (medical, surgical, or pediatric clerkship). A typical example of a clinical conference is the weekly surgical-radiology conference in which current cases from surgery are demonstrated by the radiologist. Investigation plans are proposed and therapeutic strategies discussed. Feedback is given on patients who underwent surgery. Time for questions is allotted at the end of the conference. As a follow-up to our previous report (6), we aimed to describe students' perceptions of the effectiveness of integrated radiology teaching in the undergraduate medical curriculum. A survey questionnaire was distributed during the 1997-1998 academic year to medical students in the 2nd, 3rd, 5th, and 6th years and during the 1998-1999 academic year to a sample of those in their 4th year (organ systems year 2 course), as 4th-year students had not been included in the first evaluation. In addition to background information regarding stage of medical education and sex of the student, the questionnaire included Likert-type and 0pen-ended items that focused on perceptions and beliefs about the integration of radiology teaching in the integrated biomedical, organ systems, and clinical sciences courses (Fig 1). Questionnaires were anonymously completed and returned, with a 57% response rate (99 students). Students were asked to indicate on a five-point Likerttype scale the extent to which they believed radiology had been effectively integrated in the teaching of modules and
clerkships experienced in their current course (1 = ineffectively, 5 = very effectively). They were asked to indicate how much they enjoyed the integrated approach, how useful this approach was in helping them learn and understand the material as a whole, and how much it contributed to their interest in the modules and clerkships. Students were also asked about the usefulness of a learning resource prepared by the Department of Radiology, called the Radiology Compendium~Handbook, in teaching principles of radiologic imaging, basic techniques and investigations, and radiology of the various organ systems. The structure of this booklet reflects the integrated approach. Junior and senior clinical sciences students were also asked how helpful multidisciplinary seminars and clinical conferences were in teaching clinical reasoning and problem-solving skills (1 = of no contribution, 5 = contributed a great deal). Each survey item was followed by a section inviting students to elaborate or give reasons for their responses and a final open-ended item inviting further comments and suggestions for improvements in the way radiology is integrated into the curriculum. Quantitative data were entered in the Statistical Package for the Social Sciences computer program, and standard descriptive statistics were generated and analyzed. All comparisons were two tailed, and P values of less than .05 were considered to indicate a significant difference. Since our study aimed to be both descriptive and analytical, we focused on understanding not only how students responded to items but also why they responded as they did. Individual openended questions were therefore typed out and analyzed to determine the reasons students gave for positive or negative responses to quantitative items and perceived strengths and weaknesses of integrated radiology teaching.
RESULTS The highest response rate (44 of 50, 88%) was seen in the organ systems year 2 student group and the lowest (eight of 29, 28%) in the clinical sciences year 1 group. The response rates for other student groups were as follows: integrated biomedical sciences (IBMS) course (year 2 of the curriculum), 27 of 40 (68%); organ systems year 1, eight of 25 (32%); and clinical sciences year 2, 12 of 30 (40%). The mean responses to questionnaire items by groups are shown in Figures 2-4. (For better understanding of the different courses and when they occur, see Fig 1.) Figures 2 and 3 indicate that, overall, students thought that radiology had been integrated fairly effectively into modules and clerkships and that integration was generally useful in facilitating learning and understanding (scores
967
3.5
3.5
3 ~2.5
82
09 c-
¢6 1.5
O) E L f ....... ~1~ 1 -
-
~0.5 -
•
0.5
0
o
Nadlology t:ttectlvely m~egra~eo; Figure 2. Effectiveness of integrated radiology teaching in modules and clerkships (mean scores by course) (1 = ineffectively integrated, 5 = very effectively integrated). OSC1 = organ systems course, year 1; 0SC2 = organ systems course, year 2; Jr Clin = junior clinical; Sr Clin = senior clinical.
Overall Usefulness
i--
Figure 3. Overall usefulness of integrated radiology in facilitating knowledge and understanding (mean scores by course) (1 = not useful, 5 = very useful). OSC1 = organ systems course, year 1; 0SC2 = organ systems course, year 2; Jr Clin = junior clinical; Sr Clin = senior chnical.
4.$ between 2 and 3). There were differences between groups in their responses, however, with IBMS and senior clinical sciences students apparently less satisfied in these areas, but these differences did not reach statistical significance. Most students found the Radiology Compendium~Handbook useful in teaching principles of radiologic amaging, techniques and investigations, and radiology of various organ systems. Nevertheless, again there were statistically insignificant differences between groups for the mean responses on these variables, with IBMS, organ systems year 1, and senior clinical sciences students responding less positively than their peers. The mean responses of junior and senior clinical sciences students were positive regarding the contribution of multidisciplinary seminars and clinical conferences to their learning of clinical reasoning and problem-solving skills (Fig 4). Both teaching modalities were perceived as good facilitators of these skills at an important stage of medical education and training. While senior clinical students rated clinical conferences higher than did their junior counterparts, the two groups rated multidisciplinary seminars similarly. When open-ended comments were analyzed for the reasons underlying quantitative responses, several findings emerged. First, IBMS, organ systems year 2, and senior clinical sciences students thought that inadequate numbers of integrated radiology sessions were time-tabled and that there was too little time for discussion and interaction between students and tutors. Second, IBMS students perceived that radiology sessions should be integrated in all modules and should not precede basic anatomy sessions. Furthermore, many IBMS students commented that too few sessions focused on normal anatomy, that basic principles
968
4 ~- 3 0 E
Jr Chn 1I ~• ....... Sr Clin 1
2
41.5
0.5 Multidisciplinary Seminars
GlmlCal L;onterences
Figure 4. Contribution of radiology to clinical reasoning and problem solving in multidisciplinary seminars and clinical conferences (mean scores by course) (1 = of no use or contribution, 5 -- very useful contribution). Jr Clin = junior clinical; Sr Clin = senior clinical.
were lacking, and, again, that not enough time was available for discussion. Third, organ system students thought that the radiology compendium was useful but needed more illustrations. Finally, junior and senior clinical students were more similar in their responses to multidisciplinary seminars than to clinical conferences, with more senior than junior clinical students rating clinical conferences highly.
Integration has for some time been promoted in medical education (7,15), and there is growing interest in helping students learn an integrated approach to health care that addresses the complex interaction of the many relevant disciplines (16). In most modem medical curricula there are two main approaches to integration. Horizontal integration removes boundaries between parallel parts of the course, and
vertical integration removes those between sequential areas (15). At the Faculty of Medicine and Health Sciences we combine both approaches, and for each major organ system the basic medical sciences and clinical aspects are taught together. According to the findings of this study, however, we have not yet entirely relinquished traditional departmental "ownership" of sections of the program (eg, radiology vs classic anatomy). Overall, however, we found satisfaction with integrated radiology teaching and suggestions for how it can be made more effective. The integrated approach is seen by students as stimulating, relevant, worthwhile, and successful in achieving its aims. This study has limitations. First, student perceptions would have been more meaningful had we been able to compare the traditional and integrated approaches. Second, the small size of the study limits our ability to generalize from the results. Third, we have not evaluated the perceptions of radiologists or other clinicians, although we do plan to do so. Despite the limitations, even this preliminary evaluation has helped us understand the range of issues involved in horizontal and vertical integration in our context. Our experiences might provide useful insights for other medical schools. We found discernible differences between perceptions reported by students at different stages of medical education and training. There were some general dissatisfactions among year 2 (IBMS students) and year 6 (senior clinical sciences) students, in contrast to apparently better experiences for students in years 4 and 5. Improvements in years 2 and 6 are clearly called for. The challenges and pitfalls of integration generally are not unique to our experience, and it has been reported elsewhere that the new "blueprints" for integrated courses and curricula are not always implemented as planned and that schools do not always succeed in creating completely integrated, unified learning experiences (7,15). Although our study indicates modest student perceptions regarding integration of radiology in the teaching of modules and clerkships, further study needs to be undertaken to determine the relation between an integrated approach to teaching and positive learning outcomes. We also believe that integrated courses will encourage cooperation between staff from different departments and help avoid wasteful duplication and repetition by better coordination of effort (15). One of the authors (L.E.) has taught radiology to undergraduates in several more or less traditional medical schools, in both Sweden and the United States, and his experience also supports the integrated approach. As part of future evaluations, we intend to explore teachers' views as to how integrated
radiology teaching has facilitated this strategy. At this point, however, our study suggests that integration must be structured and coordinated with great care and consideration. Having an explicit rationale, focusing on educational goals, and recognizing the need for negotiation and a commitment to interdisciplinary teaching are but a few principles that may guide the efforts of others engaged in this process. Medical educators can determine their readiness for integrated teaching by considering whether a collaborative school culture currently exists, in which teachers collaborate with each other and with students. It is important for the faculty to share a common philosophy about teaching and learning. Clearly, from the perspective of students, it is appropriate to allocate more time to radiology in the curriculum. It has been reported that students' attitudes toward radiology develop early in medical school, typically before the usual 3rd- or 4th-year radiology rotations. A 4-year longitudinal study of a medical student class from the University of Michigan documented little change in the perception of radiology throughout medical school (17). Radiology was not perceived to offer high patient contact and was intellectually exciting to only one-third of students. These results may reflect insufficient exposure to radiology, which is certainly the case in many medical schools. Recently, Freundlich and Murphy (18) surveyed medical students about choice of a radiology elective and the factors that influenced students to choose a radiology career. The results indicated that radiology instruction during the core curriculum of medical school had a marked influence on the decision to choose a radiology career. More positive attitudes can be fostered by greater student contact with radiology, the interest in high technology and multiple modalities, the opportunities for patient contact in interventional procedures, and the intellectual excitement of radiology as a clinical problem-solving tool. IEFERENCE~ ¢
1. Des Marchais JE, Bureau MA, Duma[s B, Pigeons G. From traditional to problem based learning: a case report of complete curricular reform Med Educ 1992; 36"190-199 2. Kaufman A, Mennin S, Waterman R, et al. The New Mexico experiment: educational renovation and mst~tutlonal change Acad Med 1989; 64: 285-294. 3 Moore GT, Block SD, Style CB, Mttchell R. The influence of the New Pathway cumculum on Harvard medLcal students. Acad Med 1994; 69: 983-989. 4 Harden RM, Sowden S, Dunn WR. Some educational strategies m curnculum development: the SPICES model. Medical Education Booklet no. 18. Dundee, Scotland: Association for the Study of Medical Education, 1984. 5. General MedEcal Council Tomorrow's doctors: recommendatLons on undergraduate medtcal education London, England: General Medical Counctl, 1993.
969
EKELUND
ET AL
6. Ekelund L, Lanphear J. Diagnostic radiology in an integrated curriculum: experiences from the United Arab Emirates. Acad Radio11997; 4: 653-656. 7. Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Acad Med 1998; 73(suppl):S24-S31. 8. Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993; 68:52-81. 9. Dolmans D, Schmidt H. The advantages of problem-based curriculum. Postgrad Med 1996; 72:535-538. 10. Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med 1994; 69:883-885. 11. Harden RM, Davis MH, Crosby JR. The new Dundee medical curriculum: a whole that is greater than the sum of its parts. Med Educ 1997; 31:264-271.
970
A c a d e m i c R a d i o l o g y , Vol 7, No 11, N o v e m b e r 2000
12. Hutchinson L. Evaluating and researching the effectiveness of educational interventions. Br Med J 1999; 318:1267-1269. 13. Wilkes M, Bligh J. Evaluating educational interventions. Br Med J 1999; 318:1269-1272. 14. Erikson U. Proposal guidelines for pregraduate radiology training. ECR Newsletter 1997; 3:6-7. 15. Lowry S. Strategies for implementing curriculum change. Br Med J 1992; 305:1482-1485. 16. Tresolini CP, Shugars DA, Lee LS. Teaching an integrated approach to health care: lessons from five schools. Acad Med 1995; 70:665-670. 17. Kazerooni EA, Blane CE, Schlesinger AE, Vydareny KH. Medical students' attitudes toward radiology: comparison of matriculating and graduating students. Acad Radio11997; 4:601-607. 18. Freundlich IM, Murphy WA. Medical students who choose a radiology elective: career decisions, motivations, and intentions. Acad Radiol 1995; 2:527-532.
Diagnostic Radiology in an Integrated Curriculum: Evaluation of Student Appraisal 1 Leif Ekelund, MD, PhD, M a r g a r e t Elzubeir, PhD
Rationale and Objectives. This study determined student perceptions of the effectiveness of an integrated radiology curriculum in a 6-year undergraduate medical school program. Materials and Methods. Student perceptions of the effectiveness of an integrated radiology curriculum were assessed with
a self-administered questionnaire that was developed in house and consisted of Likert-type and open-ended items. The questionnaire was distributed to 1997-1998 and 1998-1999 cohorts of 2nd- to 6th-year medical students. Quantitative data were analyzed by using descriptive statistics. Results. Ninety-nine of 173 students (57% response) returned completed questionnaires. Overall, students perceived inte-
grated radiology teaching as satisfactorily achieved and useful in facilitating learning. Compared with students in the 2nd and final years of undergraduate medical education and training, those in years 3-5 considered integrated radiology teaching to be very effective. Results of the survey suggest future modifications to improve the effectiveness of integrated radiology teaching. Conclusion. Radiology can be successfully integrated into modern medical curricula. Student comments indicate the need to structure and organize the integrated teaching better and to introduce it earlier in the medical school curriculum.
Key Words. Education, radiology and radiologists.
During the past decade many traditional medical schools have introduced integrated, problem-based programs (1-4). I/deed, the General Medical Council (5) strongly encourages "true integration of the course, both horizontal and vertical, using the term in the sense of interdisciplinary synthesis and not simply co-ordination or synchronization of departmentally based components." True integration therefore requires a recombination and coordination of previously segregated parts of the curriculum to provide unity and encourage students to adopt a holistic approach to clinical problems. Consequently, some medical schools have restructured their entire curricula to improve both horizontal (intersubject) and vertical (basic-clinical) integration.
Acad Radiol 2000; 7:965-970
From the Department of D~agnostic RadLology,PO Box 17666 (L.E.) and the Department of Medical Education (M.E.), Faculty of Medicine and Health ScFences, United Arab Emlrates University, AI Ain, United Arab Emirates ReceivedApril 26, 2000; revision requested June 7; revision received and acceptedJune 28. Address correspondence to L.E. ©AUR, 2000
In 1997 we published a description of our experiences of integrating diagnostic radiology in the medical curriculum of the Faculty of Medicine and Health Sciences, United Arab Emirates University (6). Although the benefits of problem-based, integrated teaching and learning in medicine are well documented (7-11)and there are many proponents of these educational strategies among our own faculty members and students, we still do not understand how effectively they are being applied. Indeed, given the energy and effort normally invested in the implementation of innovative curricula, evaluation of outcomes from the perspective of medical students is increasingly important to medical educators. In particular, questions are legitimately raised about whether changes in the curriculum are effective and worthy of broader application (12,13). Radiology plays an increasingly important role in modem medicine. According to available data, however, less than 1% of medical education budgets are devoted to radiology education during undergraduate training (14). The total length of undergraduate medical education varies from
965
F.M.H.S.
CURRICULUM
UNIVERSITY GENERAL REQUIREMENTS UNIT
2
PREPARATORY COURSE
INTRODUCTION TO MEDICINE ENGLISH, MEDICAL COMMUNICATION AND STUDY SKILLS CHEMICAL SCIENCES BIOLOGICAL SCIENCES i BIOLOGICAL SCIENCES 2 BIOMEDICAL SCIENCES ENGLISH, MEDICAL COMMUNICATION AND STUDY SKILLS CLINICAL COMMUNICATION HUMAN SCIENCES DEVELOPMENTAL SCIENCES PATHOBIOIA:~ICAL SCIENCES
3
HAEMATOLOGY AND IMMUNOLOGY ALIMENT2uRY SYSTEM CARDIOVASCULAR SYSTEM RESPIRATORY SYSTEM MUSCULOSKELETAL AND PERIPHERAL NERVOUS SYSTEM
4
UROGENITAL AND REPRODUCTION SYSTEM ENDOCRINE AND MEWABOLISH NEUROSCIENCES AND SPECIAL SENSES BEHAVIOURAL SCIENCES
5
JUNIOR CLINICAL ROTATION Medicine Paediatrics Surgery Family Medicine SPECIALITY ROTATION I Obstetrics / Gynaeeology I Psychiatry / Nenroseienees Medical Specialities Surgical Specialities Elective
6
7
MATHEMATICS & COMPUTING FOR SCIENCES - I, II ARABIC - I, II ENGLISH - I, If, Ill EMIRATES SOCIETY ISLAMIC THOUGHT
CLINICAL SCIENCES COURSE YEAR 2
SPECIALTY ROTATION II Obstetrics / Gynaecology 2 Emergency & Critical Care Medicine Community Medicine SENIOR CLINICAL ROTATION Medicine Paediatrics Surgery Family Medicine
8 Figure
1. Curriculum of the Faculty of Medicine and Health Sciences.
220 to 300 weeks, b u t o n l y 1 - 4 w e e k s are usually d e v o t e d to radiology. A t t h e F a c u l t y o f M e d i c i n e a n d H e a l t h S c i e n c e s o f the U n i t e d A r a b E m i r a t e s U n i v e r s i t y , w e h a v e i n t e g r a t e d r a d i o l o g y t e a c h i n g into the c u r r i c u l u m so that it is p r e s e n t e d
966
during all phases of undergraduate teaching (6). This article describes our experiences with this integrated radiology curriculum and the results of a medical student survey conducted to evaluate its effectiveness.
MATERIALS AND METHODS Students in our program are United Arab Emirates nationals for whom English is a second language, and their secondary school backgrounds often foster rote learning and memorization of information. Our faculty members are mainly of expatriate Arab, North American, European, and Asian origins. Radiology is represented in all phases of undergraduate teaching, in all organ system modules as well as clinical clerkships (Fig 1). We also participate in multidisciplinary seminars, which are included in organ systems years 1 and 2 (Fig 1). In these seminars the students present a typical case, including relevant radiologic investigations, and the tutors are available as resource persons. These sessions are a good example of problem-based learning. They usually last for 2 hours, with a general discussion toward the end of the session. Radiology is also actively involved in the various clinical clerkships (years 5 and 6 in the curriculum). The subject is presented in small-group seminars and in clinical conferences. In the group seminars, the radiology of various disorders is discussed with a problem-based orientati0n; the topic is appropriate to the student rotation (medical, surgical, or pediatric clerkship). A typical example of a clinical conference is the weekly surgical-radiology conference in which current cases from surgery are demonstrated by the radiologist. Investigation plans are proposed and therapeutic strategies discussed. Feedback is given on patients who underwent surgery. Time for questions is allotted at the end of the conference. As a follow-up to our previous report (6), we aimed to describe students' perceptions of the effectiveness of integrated radiology teaching in the undergraduate medical curriculum. A survey questionnaire was distributed during the 1997-1998 academic year to medical students in the 2nd, 3rd, 5th, and 6th years and during the 1998-1999 academic year to a sample of those in their 4th year (organ systems year 2 course), as 4th-year students had not been included in the first evaluation. In addition to background information regarding stage of medical education and sex of the student, the questionnaire included Likert-type and 0pen-ended items that focused on perceptions and beliefs about the integration of radiology teaching in the integrated biomedical, organ systems, and clinical sciences courses (Fig 1). Questionnaires were anonymously completed and returned, with a 57% response rate (99 students). Students were asked to indicate on a five-point Likerttype scale the extent to which they believed radiology had been effectively integrated in the teaching of modules and
clerkships experienced in their current course (1 = ineffectively, 5 = very effectively). They were asked to indicate how much they enjoyed the integrated approach, how useful this approach was in helping them learn and understand the material as a whole, and how much it contributed to their interest in the modules and clerkships. Students were also asked about the usefulness of a learning resource prepared by the Department of Radiology, called the Radiology Compendium~Handbook, in teaching principles of radiologic imaging, basic techniques and investigations, and radiology of the various organ systems. The structure of this booklet reflects the integrated approach. Junior and senior clinical sciences students were also asked how helpful multidisciplinary seminars and clinical conferences were in teaching clinical reasoning and problem-solving skills (1 = of no contribution, 5 = contributed a great deal). Each survey item was followed by a section inviting students to elaborate or give reasons for their responses and a final open-ended item inviting further comments and suggestions for improvements in the way radiology is integrated into the curriculum. Quantitative data were entered in the Statistical Package for the Social Sciences computer program, and standard descriptive statistics were generated and analyzed. All comparisons were two tailed, and P values of less than .05 were considered to indicate a significant difference. Since our study aimed to be both descriptive and analytical, we focused on understanding not only how students responded to items but also why they responded as they did. Individual openended questions were therefore typed out and analyzed to determine the reasons students gave for positive or negative responses to quantitative items and perceived strengths and weaknesses of integrated radiology teaching.
RESULTS The highest response rate (44 of 50, 88%) was seen in the organ systems year 2 student group and the lowest (eight of 29, 28%) in the clinical sciences year 1 group. The response rates for other student groups were as follows: integrated biomedical sciences (IBMS) course (year 2 of the curriculum), 27 of 40 (68%); organ systems year 1, eight of 25 (32%); and clinical sciences year 2, 12 of 30 (40%). The mean responses to questionnaire items by groups are shown in Figures 2-4. (For better understanding of the different courses and when they occur, see Fig 1.) Figures 2 and 3 indicate that, overall, students thought that radiology had been integrated fairly effectively into modules and clerkships and that integration was generally useful in facilitating learning and understanding (scores
967
3.5
3.5
3 ~2.5
82
09 c-
¢6 1.5
O) E L f ....... ~1~ 1 -
-
~0.5 -
•
0.5
0
o
Nadlology t:ttectlvely m~egra~eo; Figure 2. Effectiveness of integrated radiology teaching in modules and clerkships (mean scores by course) (1 = ineffectively integrated, 5 = very effectively integrated). OSC1 = organ systems course, year 1; 0SC2 = organ systems course, year 2; Jr Clin = junior clinical; Sr Clin = senior clinical.
Overall Usefulness
i--
Figure 3. Overall usefulness of integrated radiology in facilitating knowledge and understanding (mean scores by course) (1 = not useful, 5 = very useful). OSC1 = organ systems course, year 1; 0SC2 = organ systems course, year 2; Jr Clin = junior clinical; Sr Clin = senior chnical.
4.$ between 2 and 3). There were differences between groups in their responses, however, with IBMS and senior clinical sciences students apparently less satisfied in these areas, but these differences did not reach statistical significance. Most students found the Radiology Compendium~Handbook useful in teaching principles of radiologic amaging, techniques and investigations, and radiology of various organ systems. Nevertheless, again there were statistically insignificant differences between groups for the mean responses on these variables, with IBMS, organ systems year 1, and senior clinical sciences students responding less positively than their peers. The mean responses of junior and senior clinical sciences students were positive regarding the contribution of multidisciplinary seminars and clinical conferences to their learning of clinical reasoning and problem-solving skills (Fig 4). Both teaching modalities were perceived as good facilitators of these skills at an important stage of medical education and training. While senior clinical students rated clinical conferences higher than did their junior counterparts, the two groups rated multidisciplinary seminars similarly. When open-ended comments were analyzed for the reasons underlying quantitative responses, several findings emerged. First, IBMS, organ systems year 2, and senior clinical sciences students thought that inadequate numbers of integrated radiology sessions were time-tabled and that there was too little time for discussion and interaction between students and tutors. Second, IBMS students perceived that radiology sessions should be integrated in all modules and should not precede basic anatomy sessions. Furthermore, many IBMS students commented that too few sessions focused on normal anatomy, that basic principles
968
4 ~- 3 0 E
Jr Chn 1I ~• ....... Sr Clin 1
2
41.5
0.5 Multidisciplinary Seminars
GlmlCal L;onterences
Figure 4. Contribution of radiology to clinical reasoning and problem solving in multidisciplinary seminars and clinical conferences (mean scores by course) (1 = of no use or contribution, 5 -- very useful contribution). Jr Clin = junior clinical; Sr Clin = senior clinical.
were lacking, and, again, that not enough time was available for discussion. Third, organ system students thought that the radiology compendium was useful but needed more illustrations. Finally, junior and senior clinical students were more similar in their responses to multidisciplinary seminars than to clinical conferences, with more senior than junior clinical students rating clinical conferences highly.
Integration has for some time been promoted in medical education (7,15), and there is growing interest in helping students learn an integrated approach to health care that addresses the complex interaction of the many relevant disciplines (16). In most modem medical curricula there are two main approaches to integration. Horizontal integration removes boundaries between parallel parts of the course, and
vertical integration removes those between sequential areas (15). At the Faculty of Medicine and Health Sciences we combine both approaches, and for each major organ system the basic medical sciences and clinical aspects are taught together. According to the findings of this study, however, we have not yet entirely relinquished traditional departmental "ownership" of sections of the program (eg, radiology vs classic anatomy). Overall, however, we found satisfaction with integrated radiology teaching and suggestions for how it can be made more effective. The integrated approach is seen by students as stimulating, relevant, worthwhile, and successful in achieving its aims. This study has limitations. First, student perceptions would have been more meaningful had we been able to compare the traditional and integrated approaches. Second, the small size of the study limits our ability to generalize from the results. Third, we have not evaluated the perceptions of radiologists or other clinicians, although we do plan to do so. Despite the limitations, even this preliminary evaluation has helped us understand the range of issues involved in horizontal and vertical integration in our context. Our experiences might provide useful insights for other medical schools. We found discernible differences between perceptions reported by students at different stages of medical education and training. There were some general dissatisfactions among year 2 (IBMS students) and year 6 (senior clinical sciences) students, in contrast to apparently better experiences for students in years 4 and 5. Improvements in years 2 and 6 are clearly called for. The challenges and pitfalls of integration generally are not unique to our experience, and it has been reported elsewhere that the new "blueprints" for integrated courses and curricula are not always implemented as planned and that schools do not always succeed in creating completely integrated, unified learning experiences (7,15). Although our study indicates modest student perceptions regarding integration of radiology in the teaching of modules and clerkships, further study needs to be undertaken to determine the relation between an integrated approach to teaching and positive learning outcomes. We also believe that integrated courses will encourage cooperation between staff from different departments and help avoid wasteful duplication and repetition by better coordination of effort (15). One of the authors (L.E.) has taught radiology to undergraduates in several more or less traditional medical schools, in both Sweden and the United States, and his experience also supports the integrated approach. As part of future evaluations, we intend to explore teachers' views as to how integrated
radiology teaching has facilitated this strategy. At this point, however, our study suggests that integration must be structured and coordinated with great care and consideration. Having an explicit rationale, focusing on educational goals, and recognizing the need for negotiation and a commitment to interdisciplinary teaching are but a few principles that may guide the efforts of others engaged in this process. Medical educators can determine their readiness for integrated teaching by considering whether a collaborative school culture currently exists, in which teachers collaborate with each other and with students. It is important for the faculty to share a common philosophy about teaching and learning. Clearly, from the perspective of students, it is appropriate to allocate more time to radiology in the curriculum. It has been reported that students' attitudes toward radiology develop early in medical school, typically before the usual 3rd- or 4th-year radiology rotations. A 4-year longitudinal study of a medical student class from the University of Michigan documented little change in the perception of radiology throughout medical school (17). Radiology was not perceived to offer high patient contact and was intellectually exciting to only one-third of students. These results may reflect insufficient exposure to radiology, which is certainly the case in many medical schools. Recently, Freundlich and Murphy (18) surveyed medical students about choice of a radiology elective and the factors that influenced students to choose a radiology career. The results indicated that radiology instruction during the core curriculum of medical school had a marked influence on the decision to choose a radiology career. More positive attitudes can be fostered by greater student contact with radiology, the interest in high technology and multiple modalities, the opportunities for patient contact in interventional procedures, and the intellectual excitement of radiology as a clinical problem-solving tool. IEFERENCE~ ¢
1. Des Marchais JE, Bureau MA, Duma[s B, Pigeons G. From traditional to problem based learning: a case report of complete curricular reform Med Educ 1992; 36"190-199 2. Kaufman A, Mennin S, Waterman R, et al. The New Mexico experiment: educational renovation and mst~tutlonal change Acad Med 1989; 64: 285-294. 3 Moore GT, Block SD, Style CB, Mttchell R. The influence of the New Pathway cumculum on Harvard medLcal students. Acad Med 1994; 69: 983-989. 4 Harden RM, Sowden S, Dunn WR. Some educational strategies m curnculum development: the SPICES model. Medical Education Booklet no. 18. Dundee, Scotland: Association for the Study of Medical Education, 1984. 5. General MedEcal Council Tomorrow's doctors: recommendatLons on undergraduate medtcal education London, England: General Medical Counctl, 1993.
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6. Ekelund L, Lanphear J. Diagnostic radiology in an integrated curriculum: experiences from the United Arab Emirates. Acad Radio11997; 4: 653-656. 7. Schmidt H. Integrating the teaching of basic sciences, clinical sciences, and biopsychosocial issues. Acad Med 1998; 73(suppl):S24-S31. 8. Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med 1993; 68:52-81. 9. Dolmans D, Schmidt H. The advantages of problem-based curriculum. Postgrad Med 1996; 72:535-538. 10. Bordage G. Elaborated knowledge: a key to successful diagnostic thinking. Acad Med 1994; 69:883-885. 11. Harden RM, Davis MH, Crosby JR. The new Dundee medical curriculum: a whole that is greater than the sum of its parts. Med Educ 1997; 31:264-271.
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12. Hutchinson L. Evaluating and researching the effectiveness of educational interventions. Br Med J 1999; 318:1267-1269. 13. Wilkes M, Bligh J. Evaluating educational interventions. Br Med J 1999; 318:1269-1272. 14. Erikson U. Proposal guidelines for pregraduate radiology training. ECR Newsletter 1997; 3:6-7. 15. Lowry S. Strategies for implementing curriculum change. Br Med J 1992; 305:1482-1485. 16. Tresolini CP, Shugars DA, Lee LS. Teaching an integrated approach to health care: lessons from five schools. Acad Med 1995; 70:665-670. 17. Kazerooni EA, Blane CE, Schlesinger AE, Vydareny KH. Medical students' attitudes toward radiology: comparison of matriculating and graduating students. Acad Radio11997; 4:601-607. 18. Freundlich IM, Murphy WA. Medical students who choose a radiology elective: career decisions, motivations, and intentions. Acad Radiol 1995; 2:527-532.