Improving Integration of Basic Science into Clinical Medicine: Vertical Integration into Clinical Education (VICE) Activity

Abstract

The integration of basic science into clinical clerkships continues to be a challenge in medical curricula. We developed an integrated session for 3rd year medical students enrolled in OB-Gyn/Pediatric Block. The session focused on transplacental and perinatal infections, and consisted of a student-driven pedagogy activity in which students were required to explain the basic science principles behind the pathophysiology of the clinical presentations, the work-up, and the treatment of the infections. This approach helps students understand how basic science knowledge informs clinical practice and potential increase clerkship-level students’ confidence as it makes them serve as leaders of active learning modules.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-021-01485-7.

Background

Medical education curricula face difficulty in integrating basic medical science content with the clinical medicine content [1–3]. The concept of “cognitive integration” places emphasis on the value of basic science data to inform critical connections between clinical signs and symptoms and their underlying causative mechanisms while acknowledging that clinicians may not spontaneously articulate the basic science knowledge they are using in their clinical reasoning [4]. It has been demonstrated that understanding and application of basic science principles leads to superior diagnostic accuracy and better understanding of the relative importance of key clinical features [4].

Clinical medicine at Paul L. Foster School of Medicine (PLFSOM) is extensively integrated into the basic science courses in the first 2 years; however, a lack of continued formal integration of basic sciences into clinical clerkships is observed in our clerkship years as it is in other medical schools’ curricula [2]. This is not part of a new struggle, as efforts have been made for decades to bring clinical relevance to the basic sciences and to strengthen basic science in the clinical years [5]. Curricular integration continues to be a consistent challenge in medical education reform, as curricular design poses challenges for vertical integration [2, 6].

Recent proposed solutions to facilitate curricular integration call for the creation of opportunities for basic science educators to learn about the clinical application of their topical area of expertise through shadowing and collaborations with clinician educators so that they might adjust their content to fit appropriately into its clinical application [7]. A review on strategies for an integrated curriculum is beyond the scope of this communication and described elsewhere [8–11]. One option is interactive co-teaching, defined as two instructors with complementary expertise engaging students and each other during the same teaching session, instead of lecturing [12].

At PLFSOM, our goal is to enable medical students to achieve a deeper understanding of basic science principles applied to clinical problems. We developed a basic and clinical science integrated session for third year medical students enrolled in Obstetrics and Gynecology (OB-GYN)/Pediatric (PED) block and we termed the activity Vertical Integration into Clinical Education (VICE).

Activity

We implemented the activity in 2018, and we are presenting results from five sessions held between from 2018 to 2019. The activity changed to an online format during 2020 so we decided not to include those in this paper as we consider it had important differences. The activity included students participating enrolled in OB-GYN/PED block, and divided into six groups. Each group was assigned by clinicians in OB/GYN and PEDS with one of six cases involving pregnant women or neonates with prenatal or perinatally acquired infections (TORCH, including Zika virus infection) [13, 14]. Reading material regarding TORCH infections was provided 3 weeks in advance. Students were presented with the basic clinical presentation of a patient along with minimal historical data. They were allowed to ask for one item of clinical findings (history or physical exam), laboratory, or radiologic data in order to clarify their differential diagnosis. Faculty developed a set of 4 questions (1 clinical and 3 basic science) testing students' knowledge of basic science underlying each condition:

1. What is the pathogenesis of the important clinical findings of this infection?

2. What are the basic science principles of the diagnostic work-up of this disorder?

3. What are the basic science principles underlying treatment of this disorder?

4. What is your differential diagnosis?

Each case was presented by each team of students as a peer teaching activity at a Clerkship VICE session. Each team was also responsible for reviewing a peer group’s presentation and preparing questions. At the VICE session, a pre-test and post-test of 12 questions (1 basic science and 1 clinical question for each of the six TORCH cases) was administered. Each team presented their case and answered questions by the review team, audience, and faculty. Basic science and clinical faculty presented additional data and answered questions. Team performance (i.e., overall quality of the presentation, clinical and basic science content, comprehension of data presented, and collaboration within the team) was evaluated via an online poll. Votes in these polls came from peer students, although faculy present were also allowed to vote. The team with the highest score received a prize. A diagram of the design of the activity and its steps is presented below (Supplementary Fig. 1).

Results

Anonymous feedback showed that students liked having structured questions to answer, multidisciplinary faculty involved in discussions, and the linkage back to basic science from first 2 years of medical school. An overall statistically significant increase between the pretest and posttest scores was observed upon completion of the activity (p = 0.006 paired t-test) (Fig. 1).

Fig. 1.

VICE activity participation increases basic science and clinical knowledge of TORCH infections. Scatter plot of individual values with bars indicating the increase in total score. N = 5 VICE sessions. p = 0.006 paired t-test

Discussion

As students get sometimes discouraged in their attempts to understand the biological basis of medicine, by being told to stick to “‘practical clinical knowledge” [15], paradoxically, we continue trying to integrate basic science into medical education [3]. For decades, medical schools have tried to integrate the basic and clinical sciences more effectively [5]. Other approaches to promote integration have been undertaken in other medical schools, trying to include basic scientists in rounds [5], or in case discussions [16], or using clerkship students as teachers to co-present cases with clinical and basic science faculty to MS1/MS2 audience [17].

Our results demonstrate a statistically significant increase in learning. Most studies evaluate a perceived deeper understanding of basic science principles through an intervention. These may be 52% after inclusion of basic science faculty in case-discussions [16] or 92% after co-teaching supported content integration [12].

Our approach uniquely relies on clerkship students’ effort, with clinical and basic science faculty pre-screening of the material, and peer evaluation. It is important that the faculty involved not only keep the right balance of clinical and basic science, but also make sure that the material to be presented is focused, and aligns basic science evidence with patient/clinical information.

It requires clinician, basic science faculty, and administrative effort for success. Logistical barriers of attendance, location, schedule alignment of the faculty, and software used for evaluation need to be overcome for a smooth development of the activity. As a recurrent activity, it self-adjusts through continuous improvement based on students’ feedback. Overall, the feedback from students was positive (Table 1).

Table 1.

Students’ feedback on aspects of the activity that enhanced learning

It helped us to link first 2 years knowledge to clinical cases that we would see in practice
Faculty active in discussions. Bringing up relevant literature
Having to come up with questions for the group after us
Having each group focus on one topic
Interactive discussions
Having an expert opinion from the respective fields
Q and A was very useful
Collaboration of different specialists present (OB, pathology, peds, neonatology)
Peer and faculty questions
Reviewing the other group's presentation and formulating questions for their group
Having clinicians and professors available for immediate questions and commentary
Multidisciplinary approach and varied professional input
The question and answer related to different aspects of medicine and relation to first 2 years

The VICE activity is a feasible approach and presents an opportunity for students to practice application of basic science knowledge to solving clinical problems. The described activity is intended to be a model for similar activities in the future and in other clinical rotations, and may increase the knowledge and utilization of basic science in clinical decision-making.

Supplementary Information

Diagram of the activity. Diagram of the sequential components of the activity. A pre- and post-test were administered before and after the shown steps.

Supplementary Information

Below is the link to the electronic supplementary material.

Author Contribution

LH conceptualized the activity. JC, ED, DB, HL, DS, JW, and LH conducted the activity. JC, ED, and LH wrote the paper.

Availability of Data and Material

Not applicable.

Code Availability

Not applicable.

Declarations

Ethics Approval

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Consent to Participate

Not applicable.

Consent for Publication

The authors agree to the publication of this manuscript.

Conflict of Interest

The authors declare no competing interests.