Developing a complex systems perspective for medical education to facilitate the integration of basic science and clinical medicine

Examining the nexus between medical education and complexity: a systematic review to inform practice and research

BACKGROUND

Medical education is a multifarious endeavour integrating a range of pedagogies and philosophies. Complexity as a science or theory ('complexity') signals a move away from a reductionist paradigm to one which appreciates that interactions in multi-component systems, such as healthcare systems, can result in adaptive and emergent outcomes. This examination of the nexus between medical education and complexity theory aims to discover ways that complexity theory can inform medical education and medical education research.

METHODS

A structured literature review was conducted to examine the nexus between medical education and complexity; 5 databases were searched using relevant terms. Papers were included if they engaged fully with complexity as a science or theory and were significantly focused on medical education. All types of papers were included, including conceptual papers (e.g. opinion and theoretical discussions), case studies, program evaluations and empirical research. A narrative and thematic synthesis was undertaken to create a deep understanding of the use of complexity in medical education.

RESULTS

Eighty-three papers were included; the majority were conceptual papers. The context and theoretical underpinnings of complexity as a relevant theory for medical education were identified. Bibliographic and temporal observations were noted regarding the entry of complexity into medical education. Complexity was relied upon as a theoretical framework for empirical studies covering a variety of elements within medical education including: knowledge and learning theories; curricular, program and faculty development; program evaluation and medical education research; assessment and admissions; professionalism and leadership; and learning for systems, about systems and in systems.

DISCUSSION

There is a call for greater use of theory by medical educators. Complexity within medical education is established, although not widespread. Individualistic cultures of medicine and comfort with reductionist epistemologies challenges its introduction. However, complexity was found to be a useful theory across a range of areas by a limited number of authors and is increasingly used by medical educators and medical education researchers. This review has further conceptualized how complexity is being used to support medical education and medical education research.

CONCLUSION

This literature review can assist in understanding how complexity can be useful in medical educationalists' practice.

Integration of Basic and Clinical Sciences: Faculty Perspectives at a U.S. Dental School

Although dental education has traditionally been organized into basic sciences education (first and second years) and clinical education (third and fourth years), there has been growing interest in ways to better integrate the two to more effectively educate students and prepare them for practice. Since 2012, The University of Texas School of Dentistry at Houston (UTSD) has made it a priority to improve integration of basic and clinical sciences, with a focus to this point on integrating the basic sciences. The aim of this study was to determine the perspectives of basic and clinical science faculty members regarding basic and clinical sciences integration and the degree of integration currently occurring. In October 2016, all 227 faculty members (15 basic scientists and 212 clinicians) were invited to participate in an online survey. Of the 212 clinicians, 84 completed the clinician educator survey (response rate 40%). All 15 basic scientists completed the basic science educator survey (response rate 100%). The majority of basic and clinical respondents affirmed the value of integration (93.3%, 97.6%, respectively) and reported regular integration in their teaching (80%, 86.9%). There were no significant differences between basic scientists and clinicians on perceived importance (p=0.457) and comfort with integration (p=0.240), but the basic scientists were more likely to integrate (p=0.039) and collaborate (p=0.021) than the clinicians. There were no significant differences between generalist and specialist clinicians on importance (p=0.474) and degree (p=0.972) of integration in teaching and intent to collaborate (p=0.864), but the specialists reported feeling more comfortable presenting basic science information (p=0.033). Protected faculty time for collaborative efforts and a repository of integrated basic science and clinical examples for use in teaching and faculty development were recommended to improve integration. Although questions might be raised about the respondents' definition of "integration," this study provides a baseline assessment of perceptions at a dental school that is placing a priority on integration.

Integrated Medical Curriculum: Advantages and Disadvantages

Most curricula for medical education have been integrated horizontally and vertically--vertically between basic and clinical sciences. The Flexnerian curriculum has disappeared to permit integration between basic sciences and clinical sciences, which are taught throughout the curriculum. We have proposed a different form of integration where the horizontal axis represents the defined learning outcomes and the vertical axis represents the teaching of the sciences throughout the courses. We believe that a mere integration of basic and clinical sciences is not enough because it is necessary to emphasize the importance of humanism as well as health population sciences in medicine. It is necessary to integrate basic and clinical sciences, humanism, and health population in the vertical axis, not only in the early years but also throughout the curriculum, presupposing the use of active teaching methods based on problems or cases in small groups.