Understanding integration at a UK medical school: An ethnographic exploration

Abstract

Integration (joined up learning of different subjects) is an important part of modern undergraduate medical education. We argue that integration in a UK medical school is experienced principally as multiple subject learning via enquiry-based learning and requires facilitators. By analysis of student interactions and the views expressed by students and staff, we demonstrate three facets of integration: student experience, with the principal means of integration being discussions of multiple subjects simultaneously, encountering related subject matter in different sessions, and making explicit links to other parts of the course; presence of facilitators of integration such as staff liaison, awareness amongst staff of other parts of the course, integrated teaching, tutor support, group bonding, early clinical experience, and integrated assessments; existence of barriers to integration such as compartmentalisation of subjects, poor student bonding, poor attitude to certain subject matter, and boundaries between course elements.

Perspectives on integration in medical education

In the relatively recent past, teaching medical students in the basic, biomedical and applied sciences involved isolation of each discipline (Carr, 1998). Medical education has been on a journey over the last four decades from learning subjects as separate entities, to learning in an integrated fashion. The Edinburgh Declaration promoted the idea that medical schools should “pursue integration of education in science and education in practice” (Edinburgh-Declaration, 1988). Generally, medical courses today implement integration via organising subject matter by the body system to which it relates. As such the biology, physiology, anatomy, pharmacology, and associated bio-psychosocial science for each system are joined together in time and space. In this manner, integration was viewed in a molecular and cellular biology pre-clinical course in Spain, as biosciences (physiology, biology and medical physics) learned together rather than in isolation (Carreras, 1990). Problem based learning (PBL) is a type of enquiry-based learning and embodies an integrated approach with several topics learned alongside each other (Barrows, 1980; Neufeld and Barrows, 1974; Spaulding, 1969). However, there are other ways of integrating medical education for example, seminars combining basic science and clinical cases (Thanikachalam et al., 2010). More recently in the USA integration has been addressed by adding clinical correlations to pre-existing basic science course content, designing clinical learning that is delivered after related basic science learning, and clinical/basic science faculty designing sessions together (White and Ghobadi, 2023). Similarly, another institution integrated “clinical correlations” with basic science learning in the first year of their medical course (Klement et al., 2016).

Theoretically, in medical education, integration has been described as a non-specific term, with different interpretations (Benor, 1982; Brauer and Ferguson, 2015; Hays, 2013). It has been suggested that integration theoretically mixes basic and clinical science during a whole medical course; but that it can also involve “mind-body integration”, covering the impact on patients of placebo effect and maintaining hope, for example. In addition, students can be instructed in basic clinical topics in an integrated manner rather than through specialty-driven tuition. These factors making up integrated curricula best take place against a background of multi-disciplinary team working (Tresolini and Shugars, 1994). Integration can be horizontal within the same year of study or vertical between years of study and has been theorised as a ladder becoming progressively more integrated as one ascends to higher rungs (Harden, 2000; Harden and Stamper, 1999).

There is evidence that learning termed as “integrated” is valued; however with vertical integration seen as less important than horizontal integration (Brynhildsen et al., 2002). Dahle et al. have described how vertical integration was achieved in part at their university using a bi-tutor dynamic, whereby groups have a scientist and a medic tutor for the whole course. Didactic teaching in basic science was tied in with contemporaneous clinical content in later years (Dahle et al., 2002). In the USA, an integrated musculoskeletal course resulted in improvement of year ending exam results on the previous year before the changes (Saleh et al., 2004).

The above text has engaged with the literature on integration in whole or parts of different medical courses. A number of individual subjects have also been described as integrated within the context of medical student studies. To this end, for example: epidemiology has been combined with sociology (Elford et al., 1985); pathophysiology has been combined with therapeutics (Mirza et al., 2013); consultation skills with nutrition (Johnson et al., 1995); lectures with discussion of cases and targeted clinical examination (Luedke et al., 1987); observation of post mortem examination with basic science (Sanchez and Ursell, 2001).

Subject level integration has also been described by various authors within clinical skills: a cadaveric, pre-clinical, surgical demonstration of pancreaticoduodenectomy, was carried out as part of the anatomy class (Are et al., 2009); vein cannulation teaching within the third year of a medical course (Hale et al., 2011); in assessment via an integrated Objective Structured Clinical Examination (OSCE) (Furmedge et al., 2016); evidence-based medicine (EBM) integrated on a subject level into the fourth and fifth years of a medical (Liabsuetrakul et al., 2009); projects in quality improvement within an Early Clinical Experience (ECE) program (Weeks et al., 2000); patient and simulated patient (SP) video consultations with plenary sessions on theory (Irwin et al., 1989); communication skills integrated throughout a course, starting in the pre-clinical years and continuing during the clinical years (Van Weel-Baumgarten et al., 2013); computer-based simulation used to supplement basic science learning (Blanchaer, 1985); simulation used to integrate teaching of heart attack/failure with history and examination used to reach differential diagnoses and acute management practised (Gordon et al., 2006). There are therefore a number of examples of subject level integration, but a consistent definition is not obvious.

When engaging with the above examples of subject level integration, it could be argued that doing so is merely adding subjects/skills to a medical course. As has been suggested in the literature, integration on a medical course can be viewed as learning multiple subjects and skills in parallel (not simply adding subjects/skills). It is clear from the literature set out in the preceding paragraphs that there is a difficulty in attempting a coherent definition of integration in medical education. “Integration” has inconsistently been applied in the literature to describe one or multiple subject areas, and simulated experiences. Integration isn’t always overt. In a traditionally structured medical course that has isolated basic sciences teaching, knowledge of ethics can be learnt covertly through participation of model medical professionals (Hafferty and Franks, 1994).

The literature in this section has shown that integration in medical education has evolved from thinking conceptually, to organisation of a medical course based on systems of the body, and ultimately to teaching clinical subjects in correlation with basic sciences. Integration remains an imprecise term and is not consistently defined. Educational terminology must be clear and unambiguous if it is to have gravitas. We argue that the integrated experience on a medical course is related to how students experienced integration, how integration was facilitated, and what got in the way of integration and this paper highlights how all this happened on the ground. The importance of understanding the student experience of integration lies in how medical schools implement integration in their curricula. Whilst a faculty can strive to make a course integrated on paper, that doesn’t guarantee students will experience integration during their studies.

Ethnography in medical education

Ethnography in conjunction with interviews is a powerful tool in medical education research. Medical education studies have employed such methodology for several decades. At a medical school in the USA, a mixed method approach was taken using diary entries, interviews and observations. This design allowed the author to understand how students learn to cope with how uncertain clinical practice can be (Fox, 1957). A seminal ethnographic study was carried out at another medical school in the USA. The authors undertook total participant observation overtly. The objective was to observe, listen to, and question students on a daily basis. Using these methods, the authors achieved a model of the research environment that they could adapt with new observations, sometimes seeking more evidence to further explain what they had discovered (Becker et al., 1961). Another ethnographic study covered the duration of a UK medical course. It included the pre-clinical, first/third clinical years, and the first year of practice. By conducting the data collection over a full year, the observations encompassed a range of insights/experiences/aspects of student engagement with their learning. The methods chapter is not clear on the use of interviews; however the findings include comments made by students to Sinclair so it seems informal questionings were used, at least (Sinclair, 1997).

Ethnography has been used to explore the process of clinical learning on hospital ward rounds (Balmer et al., 2010). Ethnography has also been used to observe the hospital ward community and how medical and nursing students engaged with it (Hagg-Martinell et al., 2016), and interactions between medical students and doctors/patients (Atkinson, 1981). During sessions on morbidity and mortality in a Canadian Health Sciences Centre, Kuper et al. (2010) studied teaching and learning by ethnography and semi-structured interviews. Quilligan (2015) carried out a ward-based ethnographic study in order to study how fourth year UK medical students learn consultation skills whilst on ward rounds.

Ethnography can show a wide variety of facets involved in medical education and therefore is a broad-based methodology that gives the best opportunity to understand the full picture of integration. The methods we have used have been described in more detail previously, open access, in an peer reviewed journal, along with reflexivity (Morris et al., 2024). Briefly, this was an ethnographic study of early year medical students with semi-structured interviews of students and staff as part of a PhD study. Informed consent was taken from all participants. Data collection took place between 2014 and 2017. The ethnography was conducted with two different undergraduate medical student groups, in two separate and non-overlapping periods of overt, non-participant observation. Each group contained 12 members (P1-P24). 12 of these students agreed to be interviewed after the respective periods of observation. 16 members of staff who taught on the course (P25–P40) agreed to a semi-structured interview. () in the quotations indicates uncertain transcription. Quotes have been converted from their original verbatim transcription to plain English so they can be more easily read. A qualitative data analysis package (Quirkos) was used. Ethical approval was granted by a University Research Ethics Committee.

Positionality wise, an ethnographic study carried out at a medical school in the USA had the objective to understand what happened to medical students at university, above and beyond learning medicine, in respect of influencing future careers (Becker et al., 1961). These authors deliberately made no assumptions regarding this; a naïve stance we previously reported that was thought important for our study as it helped ensure the data spoke for itself, free from positional influence (Morris et al., 2024). Based on our data, in the below text we aim to answer the following research questions:

• How is integration experienced by medical students in the early years of the medical course?

• What facilitates the integrated experience for medical students?

• What barriers prevent the integrated experience from occurring?

The objective of the study was to answer these research questions using a combination of ethnography and semi-structured interviews.

The undergraduate medical programme

The medical course at this institution at the time of the research was a 5-year undergraduate entry programme, 2 semesters each year, with the first 2 years being primarily focused on theoretical learning mixed with early clinical experience and the final 3 years being primarily clinically focused. The research focused on the first 2 years of study. In years 1 and 2 learning was enquiry based via PBL combined with various other learning events including anatomy/practical classes, lectures and consultation skills as we have previously reported (Morris et al., 2024).

Student experience

We argue that the integrated experience at the medical school under study could be seen in how multiple subjects were learnt in parallel, alongside each other via a PBL process whereby learning takes place via student research and group discussion. This integrated learning of different subjects has previously been noted (Tresolini and Shugars, 1994). Previously, multidisciplinary discussions have helped demonstrate integration of knowledge (Vergel et al., 2017). Other work has similarly suggested that students’ perception of integration related to multi-subject course content compared with the more organisational view of staff (Jain et al., 2003). Students in our study showed evidence of integrated thinking in learning environments, for example in a discussion combining anatomy and physiology:

P16 said “outer ear first”. P18 was drawing to prompts from the group. He/she suggested, “Shall we do the physiology at the same time guys”. (Field Notes, PBL).

Student P18 acknowledged participation in an integrated learning experience. This can be seen in their language that is using “we” and in proposing a group-based action that is “shall we do the physiology at the same time”. Such integration via multiple subject learning is in line with the literature as above.

PBL sessions were not the only opportunity for integrated learning via multi-subject discussion. Experiencing integration via such discussions occurred in other learning environments. During a consultation skills session on mental health, the participating students could be observed to discuss clinical and psychosocial subject matter in a seamless manner. Another multi-subject discussion was observed taking place in an informal learning environment. In semester 1, the student participants met up outside their timetabled learning to discuss a poster project about smoking cessation (Morris et al., 2024). They were observed to be considering the idea of addiction alongside interventions including clinical treatment using patches, and psychosocial factors such as support groups, and a link between depression and smoking. This discussion of multiple subjects showed that the participants were able to integrate their learning independently of the formal parts of their timetabled learning.

Students also found opportunities for integration via related subject matter encountered in different sessions notably bringing patients from the PBL cases to life with simulated patients (SPs) during consultation skills sessions:

P13: like the person the patients that we see in the simulated patients in comms [consultation skills teaching sessions];

Interviewer: Okay;

P13: are the patients that the cases are based around in PBL and have similar symptoms (Interview, P13).

Staff noted features in specific and global course design linking learning environments together in an integrated manner. Microbiology (Morris et al., 2024), for example, was used by staff member P29 to illustrate integration in action. Similar content, for example hand washing and bacteriology, was experienced by students between microbiology, PBL and hospital visits: repeating and reinforcing course content and delivering an integrated experience. Encountering related subject matter across different sessions gave students the opportunity to make connections that in turn drive an integrated learning experience. Such repetitive interconnectedness has been described previously as key to integration (Mennin, 2010).

We have shown how integration takes place when learning is backed up by meeting the same subject matter in different types of sessions. This adds meaning to medical studies, by helping the students understanding the relevance and the aims of their learning. Integration has similarly been noted by others to help with adding meaning to medical studies (Muller et al., 2008). In Muller et al.’s study, integrated learning was viewed from different perspectives, including learning multiple subjects in parallel such as basic science alongside clinical skills. This aligned with our observations.

Explicit links were made between subject matter encountered in different sessions – with students making and revisiting interconnections in learning. Doing so added a further dimension to the ways participants experienced integration. In this case, with overlap between course elements, for example drawing a link between a patient appearing in both PBL and consultation skills:

P11 said, “Mrs Benson was the woman in comms and I think she said she had neighbours that looked after her”. There was a general “oh yeh” from the group. (Field Notes, PBL).

During interview the students were able to articulate explicit links between parts of the course and therefore show how they had experienced integration: such as meeting an asthma patient (simulated) in consultation skills and in GP visits. Similarly, in a retrospective study in the USA, evidence was shown of students making explicit links by reinforcement and application of basic science learning in a clinical environment. This facilitated integration and in turn helped retain knowledge (Dyrbye et al., 2007). Explicit links between basic and clinical sciences have also been noted in group project cases in Australia (Macaulay and Nagley, 2008).

Presence of facilitators

Other factors existed that contributed to facilitation of integration on this institution’s medical course. In addition to those reported below one such factor, informal peer-assisted learning, has previously been reported by us (Morris et al., 2024).

Formal or informal staff liaison

Staff member P30 highlighted a distinction between formally documented parts of the course, versus what he/she called “soft integration”. Thus key stakeholders share their knowledge of the curriculum through spontaneous conversations and encounters, and in doing so facilitate overall integration on the course.

Staff members P25, P28 and P30 referred to the “end of Phase 1 meeting” in which staff would talk through/evaluate experiences. This meeting would also allow staff to express opinions and think about improvements. Such an opportunity for curriculum planning facilitated integrated learning:

we actually tried to identify really how we can improve integration and when we are appreciating is that integration within one semester within one Year of the different aspect of the of the course is working well we identify aspects where we could improve it but we also identify that integration between the different years of the course is pretty weak and this is where actually we need to improve integration so addressing what works well we are appreciating that that doesn’t really work really well and we need to improve that (Interview, P28).

Previous work has noted the importance of such multidisciplinary team work in delivering a medical course (Tresolini and Shugars, 1994). Delivering integration is dependent upon working as a multidisciplinary team.

Global awareness amongst staff of course content

Staff demonstrated awareness of course content via referencing other subject areas whilst delivering teaching in one subject area. Such practice helps the students integrate their learning, through highlighting where there are links between different parts of the curriculum. Staff member P34 observed in interview that, when teaching students, he/she always tried to relate different topics and subject matter, and to build on knowledge the students already had. He/she highlighted that when teaching clinical histories and examination he/she tried to “relate it back to the basic sciences”.

Observing sessions in different subject areas promoted opportunities for staff to integrate their teaching. Staff member P27 talked about how sitting in sessions from a different part of the course allowed them to familiarise themselves with what was being taught, and in turn helped students to see connections between the various subjects in the course, facilitating learning. There were deliberate efforts to connect consultation skills teaching by drawing parallels with other course content:

when we’re doing our consultation skills notes we’ll look at the lectures that are on and see whether there's any relevance with them and if there is email the person and ask for the content of it so we can highlight it (Interview, P25).

Subjects taught in an integrated manner and referenced between different sessions

Lectures helped facilitate integrated learning, although as will be detailed later, lectures were also a barrier to integration in some respects. Staff member P29 observed regarding the module he/she was involved with, how “the lectures for the week” were integrated at module lead level with the core teaching of PBL, and how the introductory lecture for the module gave “evidence of integration” to the students, thereby linking course components at a curriculum planning level: in this case, lectures and PBL. Wrap-up lectures containing multi-subject content aimed to bring together the key parts of the teaching for a week’s PBL case. These wrap-up lectures were a result of staff trying to integrate teaching delivery by referencing other sessions. P9 commented:

“I like these wrap-up lectures, they help bring everything together” (Field Notes, PBL).

P9 had therefore noted that these specific lectures were integrating students’ learning.

Tutors give support that aids integrated learning

The students were observed to experience help from their PBL tutors. The student participants would ask direct questions of their PBL tutor, such as observed when Year 1 student P6 wanted to know the meaning of “chemotactic”, or when Year 1 student P1 wanted to know, with regards to HIV infection:

“what happens to the host cells DNA or does it just have both?” (Field Notes, PBL).

Year 1 student P11 talked about how they could ask the PBL tutor for guidance on how much they needed to know, and highlighted the role of the PBL tutor in formulating learning agendas:

we have the tutor there to make sure that the learning agenda stays on course (Interview, P11)

Guidance from tutors such as this was key to integrated learning, encouraging students to navigate and make connections between their multi-subject learning agendas.

During a hospital visit observation, the participating students were being given a talk by radiographers, Year 2 student P13 wanted to know more about radiation burns:

P13 asked “are people more likely to get the burns with radiotherapy?” (Field Notes, Hospital Visit).

There were therefore tutors in clinical settings, not formally part of the teaching faculty of the medical school, who contributed to the facilitation of integrated learning by providing help and support with the process of making connections between different subject areas.

Evidence of group bonding in part or all of a course, supporting engagement in integrated learning

The group learning ethos is very important to integrated learning, as shown above. Such an ethos requires that students are able to interact. In this vein, occasions were observed where students shared laughter. At a hospital visit, the group were thinking about a particular acronym for listening to patients. Two students, rather than paying attention at this point, were engaged in small talk with P4 laughing at P12’s socks (they both had Monday on and it was Friday). P12 explained he/she was in a rush that morning. We argue that here was evidence of bonding, facilitating the group togetherness at the heart of the integrated learning process at this medical school. In a PBL session discussion regarding puberty, testosterone was mentioned in terms of its risks. The following was observed amongst suggestions given in response:

P6 said “irritability, that’s just like puberty”. There was general laughter in the group (Field Notes, PBL).

We can therefore see the interpersonal dimension of the integrated learning process. The group had bonded well together, in a manner beyond normal group learning. This bonding therefore facilitated integration via establishing an environment where integrated discussions could flourish. Interactions between students including with humour has been previously reported as a mechanism for dealing with their uncertainty (Fox, 1957).

Opportunity provided for real or simulated early clinical experience

In the Consultation Skills Learning Centre (CSLC), the participating students were taught how to gather information from a patient in a structured manner using communication techniques. Here was an opportunity for facilitating the integration of clinical skills within the context of learning the sciences via the experience of using these techniques. Insight was gleaned, regarding how students understood they were learning such communication skills, in a discussion between Year 1 students P1 and P9 at the beginning of a session, where the group were invited to talk and share their thoughts amongst themselves:

P9 said to P1, “introduction, take a history, make the person feel welcome”. P1 said “open questions”. P9 said “yeh, encourage them to talk… it’s like a skill trying to get the right information out of them” (Field Notes, CSLC Session).

Staff member P36 suggested that consultation skills sessions themselves provided an arena for students to discuss different subject areas, inviting students to make connections across subject areas through their discussions. This staff member has therefore observed the importance of consultation skills to the facilitation of integration through these connections. More importantly, Year 2 student P22 noted during an interview that ECE helped them feel they were studying medicine.

During the fieldwork, participating student groups were accompanied on their visits to three different large teaching hospitals. These visits facilitated integrated learning by inviting students to consider the relationships between clinical skills and the traditional basic science studies in the early years of medical school. The format for these visits generally encompasses group discussion of a particular topic, followed by the opportunity to interview a patient on the wards (which wasn’t observed). After the completion of the patient interviews, there was a tutor-led debrief with the students. Skills useful to a consultation were covered during the aforementioned group discussions. An example observed was the mnemonic SOCRATES. This particular mnemonic was an aid memoire that prompted the questions to be covered in a medical history where pain was a presenting complaint. Topics such as pain could therefore be studied in an integrated manner from both the basic science and clinical point of view, in the context of taking a clinical history.

During interviews, Year 2 student P18 talked about learning clinical skills during physiology-pharmacology practical classes. P18 found this motivational and good preparation for the clinical years. Another student thought ECE put real-world context behind learning.

I talked to a patient on the respiratory ward at Salford hospital and that was good because you could actually you could see for real the effects of what we’d just been researching (Interview, P11).

We argue that to have such an opportunity brought to life the academic course content in a manner that facilitated integration.

Early clinical experience (ECE) on the medical course of study was found to be an important, valued process by the majority of participating students. ECE as required by the General Medical Council (GMC, 2009, 2016) is important in terms of integration, in that it should occur throughout a programme of study. A focus group study in year 1 of a UK medical course showed that clinical experience contributed to PBL learning, providing context such as the effect of illness on a patient (Orsmond and Zvauya, 2015). In our data, student feedback demonstrated the value placed on seeing a patient in real life that had a condition that a PBL case was based around. Therefore, we can see the value students place on integrated learning. Yardley et al. (2013) have found that students view ECE as something that occurs alongside to the rest of the course. This observation is contrary to the observations in the present study, and indeed studies by other authors, that suggest that ECE had an integrated function on the course in that interconnections between course areas were visible (Hampshire, 1998; O'Brien-Gonzales et al., 2001; Dyrbye et al., 2007; Von Below et al., 2008).

Assessment integrated internally and embedded as part of the curriculum

A new development at the time of this study was an integrated objective structured clinical examination (OSCE) for the Semester 3 students. The rationale for this assessment, as described by one of the staff members (P27), was the combination of communication skills, examination skills, physiology, pharmacology and anatomy. The staff viewpoint of the integrated OSCE was relatively positive and supportive. Students, having undertaken the assessment, were less complimentary:

Interviewer: Okay well tell me about the integrated OSCE

P13: It turns out it wasn’t that integrated the teaching for it they tried to tell us when we were in phys-pharm they tried to get us to think like when we were doing I don’t know let’s say when we were doing like the subdermal injections they tried to say well tell me about like the pain pathway about this and the pharmacology and try

Interviewer: mmm

P13: and get it all together but then in the actual OSCE it was completely separate (Interview, P13).

Year 2 student P18 didn’t think the integrated OSCE was integrated either, pointing out how, although the stations contained within the assessment had history taking and examination, a physical separation of the two skills occurred.

Other studies have noted integrated assessment in Years 1 and 2 of medical school such as patient histories as a base for multi-disciplinary testing, consultation skills and laboratory science, and multiple choice assessment (Benor, 1982). Additionally, students viewed a particular Objective Structured Clinical Examination (OSCE) assessment “balanced integration of clinical skills with basic science” (Furmedge et al., 2016). There is a theoretical contribution of such an assessment to integrated learning. Multiple subject areas are certainly being tested that are juxtaposed in time and space. However, some students didn’t see the assessment as integrated. The potential and value of the assessment for promoting integrated learning might therefore be lost.

Existence of barriers

Evidence of extensive subject compartmentalisation at the expense of integration both imposed by curriculum planners and by students themselves

There were divisions observed and reported amongst different subject areas. Staff observed that the actual course delivery, with subjects presented as discrete from one another, was a barrier to integration. Presenting individual subjects to the students as distinct from others could make it easier for them to be compartmentalised, confounding integration:

they try to they have a simplistic approach of the PBL case and their learning agenda and because it’s quite difficult for them to take over the case they have the tendency to say okay we’re going to do bioscience first and all of them what they do is discuss bioscience and then they are going to clinical and then after that they're going to BSS [Behavioural and Social Sciences] and then they're going to do a little bit of ethics and laws (Interview, P28).

Staff talked about the challenge of delivering a course that was integrated on paper, in such a way that it remained integrated in actual/day-to-day teaching and learning. In this respect, staff member P30 took the view that the design of the course implied integrated learning was taking place. However, P30 observed that the actual delivery of the course might make it look like separate elements as opposed to integrated teaching. During their process of learning medicine, students may need to consider a subject in isolation from other subject areas. However, the staff who see the students on an everyday basis were of the view that students were not integrating the subject matter they were learning across different areas of the course. From the student experience point of view, this compartmentalisation was a barrier to integration.

Evidence of students learning subjects in isolation, to the detriment of integration, was observed during the fieldwork. During a semester 1 PBL session, for example, it was noted that the participating students considered the specific subject molecular biology in a compartmentalised way, when they talked about transcription and translation. Other such subject specific discussions during PBL sessions included immune system hypersensitivity reactions, medical history taking skills, the anatomy of breast lymphatics, the development of the spine, and blood supply to the brain. There was therefore no clear trend in the subject content of these discussions.

We argue that compartmentalisation emerged from the data as a problem for integration and is one of the barriers to a theoretically fully integrated course. In the theoretical situation of full integration individual subjects would not be identifiable (Harden, 2000). However, such a theory assumes that a fully integrated course is possible to achieve. If it isn’t possible to achieve a fully integrated course, compartmentalisation could become part of the integrated experience. By this, we mean that at any time a student, in order to understand a particular subject area, may need to focus on it. Learning this subject area would contemporaneously still be occurring in parallel to other subjects, but at that point in time a barrier to integrated thinking must exist. The converse argument for integration however, would be that students having building blocks of subject matter enables them to bring these disparate elements together holistically to understand situations, such as within a PBL case. In conclusion overall, whilst the compartmentalisation we have described represented instances in time and may simply be part of a need for students, as part of integrated learning, to consider a single subject at that time point, various experiences and insights from student and staff suggest that moving away from individual subject learning and beginning to combine and cross-reference learning across more than one subject was challenging and presented a barrier to integration.

Poor student bonding for example lack of peer discussion, support or respect

Non-contribution to discussions has previously been reported by us (Morris et al., 2024). Due to absence of peer assistance with learning, and compromise to the flow of peer interaction during the learning process, non-contribution became a barrier to the process of integrated learning (Morris et al., 2024). Staff member P38 had expressed a view on students not being willing to share information, in some cases due to competitiveness (Morris et al., 2024), and also thought that the ethos of PBL could be compromised by the disruptive effect of a member of the group not contributing, or not getting involved. Given that the discussions that facilitate learning in PBL, as outlined above, are the principal way in which integration was experienced, disrupting the PBL process implicitly undermined integration.

Poor attitude of students/staff to certain subject matter

Behavioural and social sciences (BSS) were a part of the medical course at this institution. BSS (also called “psychosocial” by the students) were equally as important on the medical course as the basic/clinical sciences and were always included in PBL group learning outcomes. On an integrated course, all subjects should be learnt together. The seeds of division were sown in the group due to different views and starting points amongst the students for the various subject areas. This was not the fault of the students, but we argue the effect was ultimately a barrier to the integrated learning process.

It was observed during semester 1 of Year 1, P6 was much more interested in BSS subject matter than the other group members. This led to the impression of P6 being a little isolated when talking about BSS. If a group member was isolated in this way, there was the potential to compromise the group’s togetherness. Any compromise to group togetherness would put up a barrier to the integrated learning process. There was evidence that P6 was conscious of the risk of this, in a side discussion with Year 1 student P11 during a PBL session:

P11 said “I haven’t got the exact definition of a carer but…” P6 pushed his/her tablet towards P11 (they were sitting next to each other). P11 said, “I’m not reading out your notes”. P6 said, “people will get sick of the sound of my voice…” then read out the definition (Field Notes, PBL).

In general, the participating students did not have much regard for their psychosocial learning:

most of the time we are just like oh it’s just like psychosocial like no-one like everyone can’t really fit into more like really cares about it like it’s not really going to be relevant I just need to be to learn like my drugs so I can be a good doctor (Interview, P7)

Attitudes such as these made integration of these areas difficult and were therefore a barrier to integration.

Staff expressed both difficulties and resistance towards connecting their own teaching with other subjects. These subjects were outside their own area of expertise and teaching remit, therefore, we argue, resulting in a barrier to integration. Staff member P31 saw this particular difficulty as residing in the faculty itself. P31 thought that whilst the staff were well-qualified and committed, they were “very protective of their areas”. Boundaries in medical courses have previously been noted (Muller et al., 2008). These authors observed in their study that staff didn’t know about course areas other than their own and weren’t talking with colleagues or trying to interlink their teaching with that of others. Whilst we have argued above that staff liaison is an important facilitator of integration, lack of staff liaison is a clear barrier.

Clear boundaries between some or all course elements

There were boundaries in existence between certain global areas of the medical course at the institution under investigation. The knock-on effect was barriers to integrated learning. The areas where boundaries were identified included: knowledge-based, practical skills and general skills.

Knowledge-based sessions

The two strands of knowledge-based science learning were basic sciences, and Behavioural and Social Sciences (BSS). One Year 1 student, P6, postulated that the science and social parts of the course were often “quite divorced”, not seeming interlinked. Year 2 student P22 viewed the BSS elements of the course as disconnected from other course components, saying:

the BSS kind of stuff is I find the hardest stuff ‘cause it doesn’t really connect with anything it’s just kind of there and you just have to read Ogden [a textbook] or something (Interview, P22).

In this quote from P22, “it’s just kind of there” implies BSS was floating, unconnected, and somehow random and therefore not integrated. P22’s phrase “you just have to read Ogden or something”, implies no transparent connection being made for the participating students as to why BSS is core to their studies, again therefore showing a barrier to integration existed. Lack of integration of BSS is an issue that has been noted on other medical courses (Muller et al., 2008).

Lectures were delivered to the whole year group in an auditorium and then made available as podcasts. Curriculum planners intended the knowledge-based course element of lectures to support students’ learning in the other areas of the course. The implication therefore is that lectures should be integrated. However, lectures were often criticised by the participating students and this was a risk to integration. During a consultation skills session, a discussion was observed in which participating students raised issues regarding lectures, attendance at them, and their perceived poor quality:

P16 said, “are you going to lectures today?” P15 was going to the first one, not the second, as he/she didn’t learn anything in that particular lecturer’s talks. P15 talked about podcasting lectures and learning more from this. P15 pointed out that having a Parkinson’s disease lecture in the schizophrenia week wasn’t good. P14, P16 and P15 wondered why the lectures were, “shit”. P14 particularly thought that the lecturers were talking about their own research interest and he/she didn’t understand what they were talking about. P16 found that he/she got lost in lectures. P15 admitted that he/she normally daydreamt in lectures (Field Notes, CSLC Session).

In this discussion between participating students, one can see a perception of poor quality of lectures, as well as concerns regarding the placement and timing of a lecture in relation to other components with similar content. This increased the risk of lack of attention being paid to the lecture and its content. This was demonstrable by one student admitting to daydreaming. There was therefore a barrier to integration.

Year 1 student P11 expressed a view during interview (which was also echoed by Year 2 student P13 in their interview), that lectures weren’t always connected with other elements of the course. Staff members P28 and P36 commented how the lectures could be better integrated. In common with our observations, lectures have previously been noted as being of dubious value (Vergel et al., 2017) and lacking integration (Muller et al., 2008). We argue that if there is a question mark over the structural integration of lectures at a curriculum planning level, a barrier to integrated learning must exist. If students did not attend lectures this presented a barrier to integration, whether or not lectures were actually integrated. If lectures were not seen as integrated by the students, there was the potential to create a vicious circle with poor lecture attendance, therefore reinforcing the barrier to integration. Whilst lecturers may have felt it was of academic interest for the students to know about their own research areas, it can be inferred that students wanted lectures that were integrated with their learning. However, one could argue that discovering such areas of academic interest does integrate learning and that it is beneficial for students to be exposed to wider academic study. It is possible that students may engage more if lecturers made their objectives clearer. Nonetheless, in terms of the course overall the lecture programme was a barrier to the student experience of integration, despite the best intentions of curriculum planners.

Skills-based sessions

Skills-based sessions included clinical skills such as consultation skills, clinical examination, and practical skills such as dissection. Learning clinical skills on the medical course was part of the ethos to integrate clinical and basic science teaching and was generally well valued; however, not universally:

P9: sometimes especially when we did examinations after we’d been learning about the chest then we’d learn (to do) a chest examination it does but sometimes it can be a bit random

Interviewer: mmm

P9: but I think it’s still really important to do it to learn all the communication

Interviewer: mmm

P9: so yeh that’s but sometimes it’s not really relevant to the case it just kind of has to be done (Interview, P9).

When P9 says, communication skills are something that “just kind of has to be done”, this implies that P9 didn’t see a relationship between different sessions. Not seeing a relationship or connection is a barrier to integration.

Physiology-pharmacology practicals were skills-based sessions where diverse clinical and practical skills were learned (Morris et al., 2024). Again, this is in line with the ethos of integrated learning of clinical and basic sciences. Some staff observed that such physiology-pharmacology practicals lacked integration: for example, staff member P30 was unsure if, or to what extent, this area was integrated with other areas in the course. There was a tendency for anatomy (Morris et al., 2024) to be seen as a subject that stood alone, risking the integrity of integration. It was observed by P35 that the relationship between the anatomy, consultation skills and physiology-pharmacology parts of the course needed more work in terms of joining up conceptually and that the very different teaching and learning methods involved could be a little more integrated. We argue that a barrier to integration therefore effectively existed at curriculum planning level in terms of the “conceptual” integration between course areas. Methods of teaching delivery were another barrier to integration and this could be addressed by curriculum planners. There was an implied lack of integration in the difficulties with aligning and interconnecting anatomy with other course subject areas, suggesting the existence of a further barrier. However, one could also argue that anatomy could be considered part of the process of integration as it gave the opportunity to meet subject matter in a different environment that was covered elsewhere in the course.

General skills

There were boundaries between the general skills of reflection/personal and professional development (PPD), and evidence-based medicine (EBM) gained by students on the medical course. These general skills are important for integration. The key general skill the students learnt was reflection. The primary focus here is therefore PPD, of which reflection was the key part.

PPD was seen as standalone by students and staff, to the detriment of integration. PPD wasn’t seen as being integrated by Year 1 students P1 and P2, with P1 thinking that PPD was “not intended to be connected”. Staff member P37 viewed the PPD/PEP aspects of the course as standalone, however did not feel that these aspects required integration. Whilst acknowledging “the benefits of being able to reflect on your own learning”, Year 1 student P11 thought there was “far too much emphasis placed on PPD”, and also observed:

is it fair that you could despite doing very well on the course you could fail because your reflective piece isn’t up to scratch (Interview, P11).

In saying this, P11 had disconnected success on the medical course from achieving the PPD standard of adequate reflection. This disconnection presented a barrier to integration. In this vein, it has previously been reported that some students view reflection as something unbeneficial that is done simply because it is a requirement (Sargeant et al., 2011). Another study has found that a portfolio was seen by a significant proportion of students as time consuming, unfair, and subjective in its assessment (Davis et al., 2009). Further to this, 1 in 5 trainee doctors have viewed portfolio as not helpful to training (Pearson and Heywood, 2004). If reflection is not valued, then an important part of integrated learning is at risk of not being taken seriously and may compromise the important role of reflection in integrating learning in both the short and long term.

Students and staff observed that EBM could have relevance to the PBL cases, presenting a barrier to integration. Year 1 student P9 mentioned that EBM was sometimes relevant to the PBL cases, and sometimes not. Staff member P36 felt that it was hard to relate the EBM topics to the part of the course at hand and that this tended to be superficial. There was therefore a barrier to integration seen in such perceptions about the value of EBM, and its relevance to learning in other areas of the course.

Key points

The data presented in this paper regarding integrated learning highlight three key points.

Key point 1: Multi-subject discussions drove integration

We have argued that the integrated learning experience was driven principally by taking part in multi-subject discussions. While the PBL environment was most conducive to these discussions, they were also observed in other formal sessions. This integrated experience seemed to have a more general impact, influencing integrated learning behaviours in the participating students during times of informal study. Explicit links made by participating students during their discussions verbalised and reinforced their integrated learning experience.

Key point 2: Facilitators were part of a structural aspect of integration

Facilitators of integration provided a scaffold. This scaffold was the structure upon which integrated learning could be built. This structure included staff liaison, referencing of subjects between sessions, support from tutors, group bonding, early clinical experience and integrated assessment. Staff (who aren’t participating as learners on the course) bring a more global overview of integration that students may not think about. Staff would expect evidence of curriculum planning driving facilitation of integrated learning. When multi-disciplinary teaching is scheduled to take place staff would assume this would deliver integration. A key part of integration on the course was learning subjects in parallel. Staff see this as planned, and students experience it on the ground. One subject being taught and learned alongside another subject in the same week of the course was an important design feature of the curriculum. This design feature was a major structural element upon which integrated learning could be built upon.

Key point 3: Barriers got in the way of integration

The barriers we identified to integrated learning are important findings. These often relate to specific subject areas. There were boundaries between course elements, subject compartmentalisation, poor attitude amongst students/staff to certain subjects, and sometimes issues with student bonding. Whilst PBL was set up to provide an integrated experience it was not obvious that boundaries between subjects were blurred, therefore impeding integrated learning.

Conclusion

Research in this field has demonstrated that integrated learning is a difficult concept to understand. This is further complicated by the lack of an accessible way of modelling integration. It is difficult to identify the level achieved on Harden’s integration ladder (Harden, 2000), the existing model of integration, due to the complexity of the findings presented herein. Indeed, full integration as defined in this existing model of Harden’s may be impossible. There is a potential benefit in drawing together the findings from this study in a new model of integration which, would have the benefit of being evidence based. A questionnaire could then be developed from this model that assessed the degree of integration experienced by medical students.

A next step to follow on from this research would be an action research study to investigate whether students make explicit links but do not articulate them (i.e., making links implicitly). A case study could be presented to two groups of students, and a few days later a session on consultation skills could make a link explicit and obvious to one group of students, and to the other group not obvious at all. After a few weeks, both groups could be given an assessment to test their acquisition and retention of knowledge and whether it mattered if links were made explicitly or implicitly. Whether the students made the links could be investigated using simulated recall interviews (Shubert and Meredith, 2015).

Another follow-up study could assess integration in different medical schools. Such a study would employ ethnography and interviews with students and staff to understand integration at different institutions and the principles of integrated course design. There could then be an analysis of the extent to which the design of courses gave rise to the students experiencing integrated learning.

In conclusion, integration matters, because the job of a doctor is to solve clinical problems by considering and synthesising relevant background including the clinical picture, the basic science behind test results, pertinent pharmacology, and BSS aspects. Integration is therefore an important concept for medical education and medical students need to be able to learn and ultimately function as medical professionals in an integrated manner.