Integration of Basic and Clinical Sciences: Student Perceptions

Abstract

The integrated curriculum is becoming a popular concept among dental schools. The purpose of this study was to query dental students at the University of Texas Health Science Center at Houston – School of Dentistry (UTSD) to elucidate their level of interest in the integrated curriculum, perception of how much integration is currently occurring, and identify challenges to integration. To address this question, dental students at UTSD were invited to participate in a survey. Participants reported their perspectives on integration of sciences. All survey participants agreed that it is beneficial to integrate clinical and basic sciences and that basic science educators were incorporating clinical relevance in their regular teaching. The third and fourth year classes, classes that had been exposed to general as well as all specialty dentistry clinics, agreed that basic sciences are being incorporated into most clinical teaching. Top two barriers to integration identified by the students were lack of crossover knowledge of faculty, and insufficient time to explore connections between basic sciences and clinical sciences because of the volume of information that needs to be covered. In conclusion, student perception at UTSD is that overall basic and clinical sciences are being integrated throughout the curriculum.

Introduction

The popularity of the term “integrated curriculum” has grown immensely in medical education over the last three decades. Since the historic Flexner report, “Medical Education in the United States and Canada” (1910), which shaped the standards of medical education, the basic science curriculum in the first 2 years, consisting of discrete courses controlled by individual departments, had remained separate from the latter 2 years of clinical curriculum [8]. Dissatisfaction with this curricular model grew as students complained about lack of relevance and faculty complained about students’ failure to recall relevant basic science knowledge during their clinical education. This led to major curricular reforms that have focused on implementing horizontal and vertical curricular integration [2, 5].

Simply stated, horizontal integration refers to blending of disciplines, topics, and subjects in a systems-based approach. Vertical integration brings together basic and clinical sciences; it refers to a combination of basic and clinical sciences in order to break down the traditional divide between preclinical and clinical curricula, with continuing emphasis on basic science material during all the years of undergraduate education [22]. Vertical and horizontal integration of basic science and clinical curricula has been found to improve student attitudes toward basic science, [6, 13] and stimulate deeper and more comprehensive learning [7] which intends to result in better understanding of basic science principles. In 2000, Harden proposed a more in-depth and complex taxonomy of curriculum integration with respect to medical education, which is represented as an eleven-stage ladder, with discipline-based teaching (isolation) at the bottom of the ladder and full integration (trans-disciplinary teaching) at the top [11]. The emphasis is on the subjects or disciplines in the first four steps of the ladder and the following six steps emphasize integration across several disciplines, while in the final step, responsibility for the integration is on the students.

Impelled by the work of the American Dental Education Association’s Commission on Change and Innovation in Dental Education (ADEA CCI), North American dental schools, including the University of Texas Health Science Center at Houston – School of Dentistry (UTSD), have recently begun advocating for, or have implemented, integrated curricula intending to instill in students higher order thinking skills required for the practice of modern oral healthcare. In 2012, UTSD underwent curricular reform in order to implement this integration. Although basic sciences are still primarily taught in the first 2 years of the curriculum, they are horizontally and vertically integrated in the new model. Biomedical science education is delivered through a systems-based approach. General medicine and pharmacology are combined in a three-part course that is offered over 3 semesters, starting in the spring of second year, which also includes case-based discussions. In order to achieve vertical integration, problem-based learning (PBL) courses, with clinically relevant dental/medical case discussions, are introduced in the first year. Moreover, students are first exposed to the clinic environment during the first year. Similarly, basic science content is incorporated in all 4 years of the curriculum during clinical simulation and using virtual patients. In addition, evidence-based dentistry, which often harnesses basic science principles to support clinical decision-making, is now incorporated into courses throughout all 4 years of the curriculum. The overall design could be described as a “complementary program” (step 8) on the Harden’s ladder, in which the integrated sessions represent a major feature of the curriculum with subject-based teaching running parallel.

While there is a plethora of studies documenting student perceptions of such integrated curricula in medical education [2, 4, 6, 7, 13, 15, 16, 22], there are none that have addressed this question in a North American dental school. Since students are the stakeholders, who experience curricular changes firsthand, their feedback is essential in order for change to be fruitful. The purpose of this pilot study was to assess the level of student interest in an integrated curriculum. The authors define integration as a “regular manifestation of clinical relevance in basic science teaching and regular manifestation of basic sciences in clinical teaching, including delivery of patient care.” However, for the purpose of the survey, the authors intentionally left the definition of integration open ended. In this study, we tested the following null hypotheses: Majority of the students will not agree that (1) our school has been successful in introducing clinical relevance into the early part of the curriculum, (2) the basic science educators at our institution incorporate clinical relevance in their lectures on a regular basis, and (3) clinical educators at our institution incorporate basic science relevance in their regular teaching.

Materials and Methods

Institutional Review Board (IRB) approval from UTSD was received on May 31, 2016 (HSC-DB-16-0451), with designation of exempt status. All students (n = 406) at the School of Dentistry were e-mailed invitations to participate in a voluntary Qualtrics (Qualtrics, Provo, UT) online survey during the time period January 9 to January 31, 2017.

The survey (Table 1) consisted of questions regarding which year in dental school the respondent was in, their perspective on integration of sciences in teaching, and which sciences they believe are integrated. Opportunity was also given for free narrative responses to identify challenges to integration of basic and clinical sciences at the School of Dentistry. We used a thematic analysis of the data to represent the open-ended student responses [3].

Table 1.

Survey administered to students

Statistical Analyses

Descriptive analysis was provided for each question in different groups (Figs. 1, 2, 3, and 4). One sample proportional test was used for hypothesis testing. The chi-square test or Fisher’s exact test was used to evaluate the association between the answers of the students of different years at UTSD. All statistical analyses were performed by the SAS software 9.4 (Cary, NC). In addition, we performed a generalized linear model testing the effects of before and after interventions on student performance on National Board Dental Examinations (NBDE) Part I and II. These analyses were performed using the R statistical software [17].

Fig. 1.

Responses of surveyed students to questions on the importance of integration of a dental clinical examples/relevance in basic science teaching and b basic sciences in the clinical curriculum

Fig. 2.

Responses of surveyed students to questions to measure a success in introducing clinical relevance into the early part of the curriculum through problem-based learning, b integration of clinical relevance by basic scientists in their regular teaching, and c usefulness of basic science knowledge in diagnosis and treatment planning in clinic

Fig. 3.

a Percentage of total third and fourth year students who strongly agreed/agreed that basic sciences are incorporated regularly by clinicians of different disciplines in their clinical teaching. b Breakdown of student responses by year in dental school to the statement “The general dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” c Breakdown of student responses by year in dental school to the statement “The operative dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” d Breakdown of student responses by year in dental school to the statement “The prosthodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” e Breakdown of student responses by year in dental school to the statement “The pediatric dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis”

Fig. 4.

a Breakdown of student responses by year in dental school to the statement “The periodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” b Breakdown of student responses by year in dental school to the statement “The orthodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” c Breakdown of student responses by year in dental school to the statement “The endodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis.” d Breakdown of student responses by year in dental school to the statement “The oral surgeons in our institution incorporate basic sciences into their clinical teaching on a regular basis”

Results

A total of 406 dental students at UTSD (103 first year, 102 second year, 102 third year, and 99 fourth year) received the survey. A total of 231 students (63 first years, 59 second year, 56 third year, and 53 fourth year) responded to the questions, with a participation rate near 60%. Ninety eight precent of the students either strongly agreed/agreed that it is important to integrate dental clinical examples/relevance in basic science teaching (Fig. 1a) and 93% of the students strongly agreed/agreed that it is important to integrate basic sciences in the clinical curriculum (Fig. 1b). Although overall 75% of the students strongly agreed/agreed that our school has been successful in introducing clinical relevance into the early part of the curriculum through PBL, their opinion differed significantly among the different classes (P = 0.02) (Fig. 2a); while most first year students strongly agreed, the rest agreed with some being neutral and a few disagreeing. Sixty-six percent strongly agreed/agreed that the basic science educators at our institution incorporate clinical relevance in their lectures on a regular basis (Fig. 2b). Eighty-four percent of the students agreed that basic science knowledge aids them in diagnosis and treatment planning in the clinic and there were no significant differences between the 4 years (Fig. 2c). Given that only the third and fourth year students are fully exposed to all clinical disciplines, only their responses were considered for statistical analysis for the questions pertaining to clinical teaching. Of the third and fourth year students, 63% strongly agreed/agreed that the general dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a). Breakdown of results by years in dental school shows that while 71% of the third year students strongly agreed/agreed to the statement regarding incorporation of basic sciences by general dentists, only 55% of the fourth year students strongly agreed/agreed, with the difference being statistically significant between the third and fourth year students (P = 0.02) (Fig. 3b).

While 68% of the third and fourth year students strongly agreed/agreed that the operative dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a, breakdown shown in Fig. 3c), only 50% of the students strongly agreed/agreed that prosthodontist faculty do (Fig. 3a, breakdown shown in Fig. 3d). Sixty-two percent of the third and fourth year students strongly agreed/agreed that the pediatric dentists in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a, breakdown shown in Fig. 3e).

Eighty-four percent of third and fourth year students strongly agreed/agreed that the periodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a, breakdown shown in Fig. 4a). While 56% of overall responses for the third and fourth year students strongly agreed/agreed that orthodontists in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a), there were significant differences in perceptions between the two classes with more of the fourth year students disagreeing/strongly disagreeing (P = 0.001) (Fig. 4b).

In total, 83% and 79% of the third and fourth year students respectively strongly agreed/agreed that endodontists and oral surgeons in our institution incorporate basic sciences into their clinical teaching on a regular basis (Fig. 3a, breakdown shown in Fig. 4 c and d).

One hundred and fifty students in total responded to the open-ended question “What do you view as the primary challenge to integration of the clinical and basic sciences at our institution?” When the comments were analyzed, it was apparent that students viewed the following as the two primary challenges to integration of basic science and clinical curricula: (1) basic science faculty lacking clinical knowledge and vice versa and (2) insufficient time to explore connections between basic sciences and clinical sciences because of the volume of information that needs to be covered in a short time (Table 2). Other challenges identified were lack of relevance of basic science material taught within dentistry, not having clinical exposure while learning basic sciences, lack of communication between basic science and clinical faculty, and lack of appreciation for basic sciences in the clinical setting.

Table 2.

Student open-ended responses to barriers in integration

Challenges to integration of basic science and clinical curricula	Number of respondents N = 150	Sample participant narratives
Basic science faculty lacking clinical knowledge and vice versa	31	“Some of the basic sciences instructors lack knowledge of dentistry to make it relevant for us.”
Insufficient time to explore connections between basic sciences and clinical sciences because of the volume of information that needs to be covered in a short time.	27	“Time. We have so much to learn in a short time that sometimes going in-depth into any one subject is not feasible. Also, the volume of information given to us makes it hard to retain.”
Lack of relevance of basic science material taught within dentistry.	26	“Focusing on basic sciences that are generally outside the scope of the general dentist’s practice, instead of spending the time related what is relevant.”
Not having clinical exposure while learning basic sciences.	13	“Not enough clinic exposure during the first year of dental school.”
Lack of communication between basic science and clinical faculty.	8	“Lack of communication and understanding between general dentists and basic scientists. The burden usually falls to our core science instructors to make the material relevant, but within the clinical setting our dentists could improve in implementing the information.”
Lack of appreciation for basic sciences in the clinical setting.	8	“The largest challenge in integration is a lack of appreciation for the basic sciences in clinical settings.”
Other	37

To ascertain if the new curriculum improved the student performance on the NBDE Part I and II, we performed a generalized linear model testing the effects of before and after interventions. Based on the analysis for the Part I of the exam, mean (± SD) percent grades for before and after interventions were 96.0 (2.0) and 96.5 (3.7), respectively, which did not differ significantly from one another (F1, 10 = 0.0838, P = 0.7781). Similarly, for Part II of the exam, mean (± SD) for before and after were 93.6 (9.5) and 93.8 (2.9), respectively, which did not differ significantly from one another (F1, 10 = 0.0017, P = 0.9679).

Discussion

As with any major change in education, objective evaluation following implementation of change is essential for the continuation and improvement of outcomes. This study aimed to examine student perception of integration of basic and clinical sciences at UTSD. Seventy-five percent of the students strongly agreed/agreed that our school has been successful in introducing clinical relevance into the early part of the curriculum through PBL (P < 0.0001). Thus, we reject the first null hypothesis and conclude that majority of the students agreed on this issue. We also found that 66% agreed that the basic science educators at our institution incorporate clinical relevance in their lectures on a regular basis (P < 0.0001). Thus, we reject the second null hypothesis and conclude that majority of the students agreed on this issue. Similarly, overall, 68% of the third and fourth year students agreed that clinical educators at our institution incorporate basic science relevance in their regular teaching (P < 0.0001). Thus, we reject the third null hypothesis and conclude that a majority of the students agreed on this issue as well.

In a previous study, we showed that faculty at UTSD perceived that clinical sciences are satisfactorily integrated into basic science courses at UTSD and vice versa [20]. Results of this current study tally with the results of the previous study, suggesting that, to a large extent, student and faculty perceptions are concordant.

In introducing the revised first-year dental curriculum, in order to effectively achieve integration of basic and clinical sciences at UTSD, different pedagogical strategies have been utilized. The primary change that was made was the introduction of Clinical Applications I and II, PBL courses in the first-year curriculum in which students work in groups of 6–7, to integrate clinical relevance in early in the curriculum. Clinical Applications I, taught in the fall semester, introduces students to the basics of evidence-based dentistry, performing literature searches and creating weekly presentations on dental cases relevant to the material given that week in courses running parallel such as Oral Biology I and Biomedical Sciences Core. Oral Biology I horizontally integrates microbiology, immunology, and genetics, while Biomedical Sciences Core integrates complex subjects such as biochemistry, cell and molecular biology, anatomy, and histology. Clinical Applications II, offered in the spring semester, follows a similar model and is designed to emphasize the clinical relevancy of the material taught in Human Biology course, which is a systems-based course that integrates physiology, anatomy, and histology. The format of Clinical Applications II however is different from that of Clinical Applications I. In Clinical Applications II, the cases are of medically complex patients with some dental relevance, with each case running over a period of 3–4 weeks, until a given system is completed in Human Biology and the students are required to individually research learning issue topics and present them to their group members at each session. In both PBL courses, in order to ensure that all students have equal exposure to these discussions, the faculty who serve as facilitators are provided with in-depth facilitator guides and are calibrated through this process. In assessing the perception of four classes of students who have gone through this curriculum, our results suggest that the students are satisfied with this restructured basic sciences curriculum. It is important to note that PBL serves as the only formal mechanism for discussion of clinically relevant cases in the first year of the curriculum. Fewer students felt that the basic science faculty were successful in incorporating dental relevance in their regular teaching. This reflects the fact that although some basic science educators incorporate clinical examples in their didactic teaching, not all do.

Responses of students in third and fourth years of dental school were mostly similar for questions regarding incorporation of basic sciences by dental specialists; however, there were significant differences in their responses concerning general dentists and orthodontists, with fourth year students agreeing less. Given that both classes were exposed to the same curriculum, this finding is somewhat curious and makes one wonder whether the more educated, the more one is aware of need for improvement in the environment. More investigation is required in order to understand why perceptions of fourth year students are different from the third year students for the two disciplines.

Lack of continued formal integration of the basic sciences in clinical teaching is a drawback of the current curriculum at UTSD. In order to bridge this gap, clinical simulation has been utilized at UTSD as an effective pedagogical tool to demonstrate the relevance of basic science principles to the practice of clinical medicine. A few examples in the literature that evaluate simulation as a means to teach basic sciences reinforce simulation as an effective pedagogical tool ([9, 10, 12, 14, 18, 21]).

It is interesting to note that students identified lack of crossover knowledge of faculty as a primary barrier to integration. It is not clear on what basis students made this comment. However, in our previous study, “unfamiliarity with clinical/basic science information” was not chosen by the faculty as an important barrier to integration (UTSD). Nevertheless, common themes identified in the feedback provided by faculty on how to improve integrated curricula included creating a repository of examples of integration of basic and clinical science which could be incorporated in teaching, and training of faculty on how to integrate clinical and basic science teaching [20].

The effectiveness of an integrated curriculum in preparing students for national standardized exams has been debated over the years. One recent study concluded that students following a discipline-specific curriculum obtained similar scores on the United States Medical Licensing Examination (USMLE) step 1 to students following an integrated curriculum [19]. Another study showed that student performance in USMLE step 1 was significantly higher among students who followed an integrated curriculum as compared with students who followed a traditional curriculum [23]. However, our analysis of UTSD student performance on the NBDE Part I and II did not show a significant difference between the integrated and the traditional curriculum. NBDE averages of our students were high to begin with, and therefore, perhaps curricular change did not have a significant impact on improving scores further.

In the context of dental education, it would be beneficial for future studies to be directed at determining whether the introduction of an integrated curriculum at UTSD improves retention of knowledge and student performance. In addition to curricular integration, changes in methods of formative assessment have been shown to improve standardized testing outcomes. An increase in the number and quality of higher-order exam questions, and emphasizing in-depth discussion in PBL sessions by introducing small-group quiz exercises have been shown to increase USMLE step 1 scores of medical students [1].

More than better performance in standardized national exams, the goal of implementing an integrated curriculum is to produce dentists who are doctors specialized in oral health. This has become increasingly imperative given the advancing age and complexity of patients. Due to advancements in medicine, people are surviving to older age, frequently with multiple systemic comorbidities. Cancer survival, immunosuppressive therapy, transplant medicine, and polypharmacy are becoming increasingly common. Given that the patient population is becoming more medically complex, it is clear that the dentist of tomorrow will need to understand biomedical sciences at a deeper level to manage such patients. Greater emphasis on basic sciences in the third and fourth years is important to reinforce the scientific basis of oral healthcare and to encourage graduating practitioners to approach diagnosis and treatment planning from the biomedical perspective. On the other hand, demonstrating the relationship between scientific fundamentals and patient care for early learners is equally important, in order to encourage the students to understand the connections between the patient as a whole and the micro-processes that underpin disease and therapeutics.

Several potential limitations exist in this study. Although the overall average of responses by all four classes gives the impression that clinicians at our institution satisfactorily incorporate basic sciences into their regular teaching, one might question what the students understand by the term “regular” in this context and what they understand by the term “basic sciences.” Differences in interpretation of these terms may have led to inconsistency in the students’ responses. We also had only near 60% response, which could have affected the reliability of our survey’s results due to higher variability. Non-response could have led to bias. Finally, due to the potentially unique curricular organization at UTSD, faculty habits, and perception expressed by students, in addition to small size of the study, even if the data are valid, the conclusions of this study may not necessarily be generalized to other dental schools. Despite the limitations, even this preliminary study has helped us identify the range of issues involved in horizontal and vertical integration at our institution and our experiences might provide useful insights for other dental schools.

We conclude from this study, student perception at UTSD is that, overall, basic and clinical sciences are being integrated throughout the curriculum. The fourth year students, however, perceived less integration in general dentistry and orthodontic clinic teaching, compared with the third year students. Future studies will explore objective measures of actual integration of basic and clinical sciences.

Funding Information

This project was funded by the Dean’s Small Grants Program at the UT School of Dentistry.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

Institutional Review Board (IRB) approval from UTSD was received on May 31, 2016 (HSC-DB-16-0451), with designation of exempt status.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the NCATS.