|Year : 2022 | Volume
| Issue : 2 | Page : 109-115
Comparison of performance of undergraduate medical students trained in conventional and integrated curriculums
Seyyedha Abbas1, Naushaba Sadiq2, Tabassum Zehra3, Ihsan Ullah4, Humera Adeeb4
1 Biochemistry/Medical Education, Pak International Medical College, Peshawar, Pakistan
2 Medical Education Department, National University of Medical Sciences, Rawalpindi, Pakistan
3 Department of Medical Education, Aga Khan University, Karachi, Pakistan
4 Medical Education Department, Khyber Medical University, Peshawar, Pakistan
|Date of Submission||10-Sep-2021|
|Date of Acceptance||03-May-2022|
|Date of Web Publication||21-Jun-2022|
Dr. Seyyedha Abbas
Pak International Medical College, Peshawar
Source of Support: None, Conflict of Interest: None
Introduction: Foundation University Medical College is one of the few institutions in Pakistan that have developed an Integrated Modular Teaching Program. This mode of teaching is a novel addition to our conventional system and needs evaluation.The objective of this study was to compare the overall cumulative results of undergraduates from (Group A/2015) conventional (old) with (Group B/2016) integrated (new curriculum) final professional examinations and to correlate the overall cumulative results of final professional examinations with their admission test results.
Materials And Methods: We compared the final professional examination results of Group A and Group B undergraduates. Both the groups had identical final examinations in terms of pattern, subjects, examiners, and duration. In addition, a measure of central tendency and standard deviation was calculated and made comparisons between entry and final professional examination results. Finally, the t-test was used to compare the theoretical and practical scores. In addition, it established the reliability and validity of the results.
Results: The overall performance of undergraduates who trained on integrated curriculum (97.0%) was better than that of undergraduates who had trained on conventional curriculum (85.2%). Comparison between the various components of the professional examinations using the ANOVA test also revealed that the same group of undergraduates performed better with P < 0.05, which is 0.002, which showed significant results. Cronbach's alpha for overall performance was 0.957, whereas for the theoretical and practical examinations, it was 0.792 and 0.897, respectively.
Conclusion: The results revealed that the undergraduates who had trained on integrated curriculum had improved performance in the final professional examinations both in theory and practical.
The following core competencies are addressed in this article: Medical Knowledge, Practice-based learning and improvement, Systems-based practice, and Interpersonal and communication skills.
Keywords: Assessment, conventional curriculum, faculty development, integrated curriculum, medical curriculum
|How to cite this article:|
Abbas S, Sadiq N, Zehra T, Ullah I, Adeeb H. Comparison of performance of undergraduate medical students trained in conventional and integrated curriculums. Int J Acad Med 2022;8:109-15
|How to cite this URL:|
Abbas S, Sadiq N, Zehra T, Ullah I, Adeeb H. Comparison of performance of undergraduate medical students trained in conventional and integrated curriculums. Int J Acad Med [serial online] 2022 [cited 2022 Jul 2];8:109-15. Available from: https://www.ijam-web.org/text.asp?2022/8/2/109/347821
| Introduction|| |
The curriculum document is intended to be dynamic to reflect the changing societal and national needs. This is especially true in the case of the medical education curricula. Biomedical sciences and their practices are undergoing rapid evolution on a global scale. As a result of these fast developments, the medical curriculum must adapt. As the community becomes more knowledgeable, it is necessary to include fresh trends into the curriculum. Integration or transdisciplinarity is a term that arose from the cognitive study on medical education.,,,
The literature supports the necessity for a push for curriculum revision in response to medical education breakthroughs and changes. Pakistan's current curriculum is mostly discipline based. There is, however, a trend toward integrated curricula. Pakistan's medical education literature is devoid of evidence-based, strong research at a time when the clamor for reform is resonating across the country's medical education sector.,,
In keeping with the national and international trend of launching the integrated system, Foundation University Medical College (FUMC) has also adopted the change. As a result, FUMC has successfully implemented the Integrated Modular System in 2016, which involves integrated curriculum, teaching and learning strategies such as small group sessions, problem-based learning, and integrated assessment.
FUMC performed a pilot study to determine the efficacy of the new integrated system-based curriculum. The pilot study's overall experience was encouraging. Although junior faculty provided encouraging comments, they expressed concern about increasing effort due to the limited number of faculty members and urged that faculty strength be raised before implementing the new system., These methodologies were implemented during this study. Despite increasing the number of faculty and their training needs identified in the pilot's study still a lot of resistance was faced from all the stakeholders which is also evident from literature.,
The study compared and evaluated conventional and integrated curriculums in terms of performance in theory and practical examinations by students of both the groups.,, As the students of Group A (2015) had gone through conventional curriculum in which the subjects were taught separately in year-wise manner from the 1st year to the 4th year and were exposed to clerkship rotation in the final year, whereas the students of Group B (2016) had gone through integrated curriculum from the 1st year to the 4th year and were exposed to clerkship rotation in the final year. It is important to note the clerkship rotation of both the groups was similar in terms of curriculum. The change in curriculum at FUMC was a need-based intervention to deal with the current issues regarding undergraduate medical education worldwide. With this study, an effort is being made to implement curriculum changes that may help address issues related to implementing the integrated system, the most daunting being faculty resistance., The study may also provide information that may lead to more informed curricular decisions by the university administration. As there is a lack of evidence regarding the educational effectiveness of different models of an integrated curriculum in our society, this study may provide modest evidence for the effectiveness of the integrated curriculum in our setup. The evidence generated may lead to enhancement of the learning abilities and skills of the graduating students. Furthermore, it may help convince the stakeholders about its utility which will also facilitate the wholehearted implementation of the system. Many institutions face resistance from their stakeholders, especially the faculty members, during the new integrated system implementation. Therefore, this study may help to provide some evidence for the implementation of the integrated curriculum.
| Methods|| |
A cross-sectional comparative research was undertaken at FUMC. The study was conducted on undergraduates who completed their 5 years of MBBS through the conventional curriculum (Group A/2015) and those who completed their 5-year study through integrated curriculum (Group B/2016). The overall sample size/number of participants was 202. Each group consisted of 101 students divided into two groups. All final-year medical undergraduates in Group A and Group B completed their studies from year 1 to year 5 at FUMC (Annexure). We collected three distinct sets of data for the research: first, the entry test scores for all undergraduates in Groups A and B (when they entered medical school); second, the scores of 5th-year final professionals for Group A; and third, 5th-year scores of professional examinations for Group B. Data were retrieved from the examination cell. The inclusion criteria was all final- year medical undergraduates in Group A and Group B who had completed their studies from year 1 to year 5 at FUMC, whereas the students who got transferred from other universities to FUMC after the 2nd year and those who were unable to sit in the examinations owing to their low academic performance were excluded from the study.
We compared the final professional examination scores of graduating students from both the groups (A and B). Within each group, a comparison was made between students' performance with individual admission (entry) test results. The examination model, subjects, examiners, and duration were kept the same for both the groups. Measures of central tendency, mean, and standard deviation were calculated for both the groups. In the end, theory and practical scores from both the groups were compared with each other using t-test. P < 0.05 was considered statistically significant. The reliability and validity of the scores were also ensured.
The data were obtained with the agreement of the (FUMC) Islamabad's Ethical Review Committees (ERC).
| Results|| |
Frequencies and percentages of male undergraduates in Group A were 25 (23.8%) and 30 (28.7%) in Group B. Majority were female undergraduates in both the groups, in Group A 75 (77.2%) and Group B 70 (72.3%). A total of 182 (91.6%) undergraduates passed, with 84 (84.2%) and 97 (97.0%) passing undergraduates in both Groups A and B, correspondingly. The presentation and total outcome variance were statistically significant in both the groups (P = 0.002), as indicated in [Table 1].
|Table 1: Evaluation of overall performance among gender in two groups (n=202)|
Click here to view
The average of the total scores in both was 1135.37 ± 124 and 1206.55 ± 100, respectively, statistically nonsignificant (P = 0.154) [Table 2]. The overall performance of undergraduates who underwent an integrated curriculum was (97.0%) improved compared to the undergraduates who underwent an outdated program (85.2%). By performing the reliability analysis, Cronbach's alpha is 0.957 for mentioning the overall performance as well as theory, and practical is 0.792 and 0.897, respectively, as shown in [Table 3].
|Table 2: Association of total summative marks between both the groups (n=202)|
Click here to view
|Table 3: Assessment of Total Summative Mark between both the groups (n=202). Cronbach's Alpha=0.957|
Click here to view
Pearson correlation of total professional scores with entry test scores among undergraduates in Groups A and B was judged individually. There was no relationship between the final professional examination scores and entry scores that were statistically not substantial [Table 4].
|Table 4: Pearson correlation of total marks/entry test score between students –|
Click here to view
The individual subject scores were compared for both the groups (A and B), the variance in total scores in medicine, surgery, obstetrics and gynecology and pediatrics was noted. The mean difference and P values in these subjects for both the groups is shown in [Table 5].
|Table 5: Comparison of undergraduate scores (Groups A and B) of different subjects (total) using analysis of variance (n=202)|
Click here to view
| Discussion|| |
In this study, the performance of graduating doctors has been compared in the final professional examination after imparting training in two different curricula. It is established from the results that students of integrated modular curriculum have shown better scores in theory and practical examination than students of conventional curriculum.,, Literature shows that isolated subject-based teaching without vertical integration of clinical subjects does not inculcate critical thinking among students, however, both horizontal and vertical integration with active student participation has improved students' performance in preclinical years.
Almost 15 years ago, we adopted an integrated system in many of the medical colleges in Pakistan. This implementation faced a lot of resistance, though integrated curricula are being implemented throughout the world as an essential milestone to ensure coordination in teaching activities.
In response to the faculty resistance and finding quantitative contextual evidence of the impact of the new curriculum, this study was conducted at FUMC after implementing an integrated teaching system. The study assessed the competencies of students after being trained on a new system of integrated teaching represented as Group B and other groups represented as Group A, being trained on a conventional system.,
Rehman et al. reported that students and faculty are very well satisfied by the practicality and adequacy of integrated teaching programs compared to existing teaching programs.
On the other hand, except for some universities in Pakistan, such as Aga Khan University (AKU) and Ziauddin Medical University, there is a general perception that this new system is becoming a matter of challenge for other institutions because of worsening or decreasing levels of the knowledge, skills, and attitudes of medical students.,,
Regardless of much evidence, most medical colleges are still on traditional systems. Many medical schools are not vertically or spirally integrated. Jippes and Majoor (2011), in recent research, provided an examination of medical schools with integrated curriculum. This study included 63 countries and more than 10 curricula were taken from each country. It was found that only 14% of all the medical institutes in Pakistan have implemented integrated curricula, whether horizontal or vertical.,,
In this study, the scores of two groups of students were compared trained on two different curricula, where the scores of students of Group B of new curriculum were higher than Group A, trained on conventional curriculum.,
In addition to comparing overall scores, an analysis of the impact of a new curriculum on domains of learning (knowledge and skill) has been done, and a comparison of scores in different subjects has also been carried out both in theory and practical examinations of both the groups.,
The improved performance was seen both in knowledge and skill components as Group B scored better than Group A in theory and practical examinations of medicine, pediatrics, and obstetrics and gynecology. In the theory paper, medicine, pediatrics, and obstetrics and gynecology, the performance of Group B was better with a significant difference (P ≤ 0.005).,
Literature also provides evidence of better performance in communication skills after being trained on integrated curricula. Other studies showing improved results after the implementation of integrated curricula support the findings of the current study.
The results in the subject of surgery showed improved performance of Group B in the practical examination in comparison of Group A, with P < 0.005, however, no significant difference was found in the theory paper of both the groups. The better scores in the practical examination can be explained because Group B has received early clinical exposure and more opportunity of practicing skills starting from year 1. Similar results were reported of a study after a 7-week training of students in integrated curriculum with rotation in a child health specialty at University of Wales College of Medicine. There was a better understanding of students in surgical, medical, and psychological problems of children.
Another study conducted from 2005 to 2009 on orthopedic residents showed an encouraging effect on the trainees in terms of improved knowledge after the implementation of integrated anatomy curriculum.
Lube et al., 2010, also reported improved scores of year 1 and 2 residents in surgery after training with a new integrated curriculum, and the P value was statically significant, supporting our study. Many other similar studies have shown the improved performance of students with an integrated modular curriculum. In addition, a comparison of total summative marks between the two groups reveals that Cronbach's alpha for overall performance in both the groups is 0.744, indicating that the general dependability of the group result has relatively high internal consistency. Cronbach's alpha values for the theoretical and practical examinations are 0.691 and 0.746, respectively, indicating that the skill components show a higher value than the knowledge components.
Individual subjects (both theoretical and practical) were compared across both the groups (A and B) utilizing reliability analysis and Cronbach's alpha values for all individual subjects across both the groups. The study results have provided evidence that an integrated curriculum had a positive impact in improving students' learning and performance compared to a conventional curriculum. This evidence can be used as a reference by regulatory bodies and the Higher Education Commission to improve our national practices by promoting the implementation of the integrated curriculum. [18,41-43]
For the future direction of this study, it is suggested that such studies are to be conducted at more than one institution and should compare results for the reliability of the findings. Similarly, such studies should be conducted in the clinical setting. They should compare students' performance for both integrated and conventional curricula, and results should be disseminated to all stakeholders for improvement in health care.,,
| Conclusion|| |
The study results indicated that graduating students who had gone through their 5 years on integrated curriculum performed better in their final professional examinations (theory and practical). Academic performance was shown to be positively related to the integrated curriculum.
The study's weakness is that it was conducted at a single institution. The input/feedback of faculty and students may also have been included to bolster the validity of the study's findings. In the future, expanding the research potential must cater to a greater number of students from several institutions. In addition, it is advised that a multicenter study be done including the institutions where the integrated system is deployed to provide a database on which to make critical medical school and workforce choices.
The following core competencies are addressed in this article: Medical knowledge, system-based practice, practice-based learning, and improvement.
Additional author notes
Quality and rigor of the study
- Positionality: It adds to the ethics and rigor of quantitative research. An orientation session was held during which students were informed about the project; this session also aided in creating rapport and instilling trust in students (Ng et al., 2018), who were assured that their data would remain secret. Due to the researcher's unequal connection with the study's participants, the researcher's duties were made plain at the orientation session.
Ng SL, Baker L, Cristancho S, Kennedy TJ, Lingard L. Qualitative research in medical education: methodologies and methods. Understanding Medical Education: Evidence, Theory, and Practice. 2018:427-41.
- Reproducibility: The researcher has explained the methodology in detail making the reproducibility of the study possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Ethical conduct of research
The authors certify that this scientific work adheres to the EQUATOR Network's standards for positionality, formatting, and reproducibility. In addition, the authors confirm that this was judged to need Institutional Review Board/Ethics Committee permission, with the protocol/approval number: 204126-ED-ERC-16 (AKU), FF/FUMC/17-Phy/15 (FUMC).
| References|| |
Velthuis F, Varpio L, Helmich E, Dekker H, Jaarsma AD. Navigating the complexities of undergraduate medical curriculum change: Change leaders' perspectives. Acad Med 2018;93:1503-10.
Kuzma J, Kolodziejczyk I. Current trends in medical education: Role of rural placement. Contemp PNG Stud 2018;29:51-62.
Brauer DG, Ferguson KJ. The integrated curriculum in medical education: AMEE Guide No. 96. Med Teach 2015;37:312-22.
Jamil A. Perception of environment and educational outcomes by students and faculty in traditional versus integrated curriculum. J Coll Physicians Surg Pak 2018;28:945-9.
Ahmed SD, Mubeen SM. Exploring teaching style in an undergraduate medical college following traditional curriculum in Pakistan. J Pak Med Assoc 2013;63:1409-14.
Khan MJ, Sethi A. The integrated curriculum: Call of modern era. J Ayub Med Coll Abbottabad 2020;32:285-6.
Bhutto H, Kaloi AR, Bhutto S. Suggestions to revamp madrasah curriculum in Pakistan. Int J Edu Sci 2020;28:54-62.
Tsai YD, Tsai SH, Chen SJ, Chen YC, Wang JC, Hsu CC, et al.
Pilot study of a longitudinal integrated disaster and military medicine education program for undergraduate medical students. Medicine (Baltimore) 2020;99:e20230.
Tsang A, Harris DM. Faculty and second-year medical student perceptions of active learning in an integrated curriculum. Adv Physiol Educ 2016;40:446-53.
Davis MH, Harden RM. Planning and implementing an undergraduate medical curriculum: The lessons learned. Med Teach 2003;25:596-608.
Harrison CJ, Könings KD, Schuwirth LW, Wass V, van der Vleuten CP. Changing the culture of assessment: The dominance of the summative assessment paradigm. BMC Med Educ 2017;17:73.
Barton KL, Schofield SJ, McAleer S, Ajjawi R. Translating evidence-based guidelines to improve feedback practices: The interACT case study. BMC Med Educ 2016;16:53.
Anderson WL, Mitchell SM, Osgood MP. Comparison of student performance in cooperative learning and traditional lecture-based biochemistry classes. Biochem Mol Biol Educ 2005;33:387-93.
Taradi SK, Taradi M, Radic K, Pokrajac N. Blending problem-based learning with Web technology positively impacts student learning outcomes in acid-base physiology. Adv Physiol Educ 2005;29:35-9.
Schmidt HG, Van der Molen HT, Te Winkel WW, Wijnen WH. Constructivist, problem-based learning does work: A meta-analysis of curricular comparisons involving a single medical school. Educ Psychol 2009;44:227-49.
Davis JM, Janczukowicz J, Stewart J, Quinn B, Feldman CA. Interprofessional education in dental education: An international perspective. Eur J Dent Educ 2018;22 Suppl 1:10-6.
Hall BA, Keeney A, Engstrom D, Brazzel P. Confronting the traditional system: A qualitative study on the challenges to school based restorative practices policy implementation. Contemp Justice Rev 2021;24:1-23.
Alghamdi AK. The effects of an integrated curriculum on student achievement in Saudi Arabia. Eurasia J Math Sci Technol Educ 2017;13:6079-100.
Majerník J, MaD'ar M, Mojžišová J, editors. Integration of Virtual Patients in Education of Veterinary Medicine. 2017 Federated Conference on Computer Science and Information Systems (FedCSIS). IEEE; 2017.
Akram A, Rizwan F, Sattar K, Hadi JI, Meo SA. An approach for developing integrated undergraduate medical curriculum. Pak J Med Sci 2018;34:804-10.
Azer SA, Hasanato R, Al-Nassar S, Somily A, AlSaadi MM. Introducing integrated laboratory classes in a PBL curriculum: Impact on student's learning and satisfaction. BMC Med Educ 2013;13:71.
Ten Cate O, Borleffs J, van Dijk M, Westerveld T; Numerous Faculty Members and Students Involved in the Subsequent Utrecht Curricular Reforms. Training medical students for the twenty-first century: Rationale and development of the Utrecht curriculum “CRU+”. Med Teach 2018;40:461-6.
Noureldin YA, Lee JY, McDougall EM, Sweet RM. Competency-based training and simulation: Making a “valid” argument. J Endourol 2018;32:84-93.
Alanazi AA, Nicholson N, Thomas S. The use of simulation training to improve knowledge, skills, and confidence among healthcare students: A systematic review. Internet J Allied Health Sci Pract 2017;15:2.
Rehman R, Ali R, Moazzam H, Shaikh S. Utilization focused evaluation at Bahria University Medical & Dental College. Pak J Med Sci 2017;33:849-53.
Naz AS, Rehman R, Jamil Z, Ahmed K, Surti A. Students' perceptions of usefulness of Anatomy demonstrations in traditional and hybrid undergraduate medical education curricula. J Pak Med Assoc 2017;67:461-4.
Inam SB. Experience of teaching critical appraisal of scientific literature to undergraduate and postgraduate students at the Ziauddin Medical University, Karachi, Pakistan. Int J Health Sci (Qassim) 2007;1:119-24.
Jippes M, Majoor GD. Influence of national culture on the adoption of integrated medical curricula. Adv Health Sci Educ Theory Pract 2011;16:5-16.
Rubright JD, Jodoin M, Barone MA. Examining demographics, prior academic performance, and United States medical licensing examination scores. Acad Med 2019;94:364-70.
Davoudi F, Esmaeeli S, AhmadzadAsl M, Nojomi M. Academic performance in Iranian medical students during the pre-clinical stage. Med J Islam Repub Iran 2017;31:14.
Gurpinar E, Musal B, Aksakoglu G, Ucku R. Comparison of knowledge scores of medical students in problem-based learning and traditional curriculum on public health topics. BMC Med Educ 2005;5:7.
Meo SA. Evaluating learning among undergraduate medical students in schools with traditional and problem-based curricula. Adv Physiol Educ 2013;37:249-53.
Srinivasan M, Wilkes M, Stevenson F, Nguyen T, Slavin S. Comparing problem-based learning with case-based learning: Effects of a major curricular shift at two institutions. Acad Med 2007;82:74-82.
Schmidt HG, Machiels-Bongaerts M, Hermans H, ten Cate TJ, Venekamp R, Boshuizen HP. The development of diagnostic competence: Comparison of a problem-based, an integrated, and a conventional medical curriculum. Acad Med 1996;71:658-64.
Kaper MS, Reijneveld SA, van Es FD, de Zeeuw J, Almansa J, Koot JA, et al.
Effectiveness of a comprehensive health literacy consultation skills training for undergraduate medical students: A randomized controlled trial. Int J Environ Res Public Health 2019;17:E81.
Yan Q, Ma L, Zhu L, Zhang W. Learning effectiveness and satisfaction of international medical students: Introducing a Hybrid-PBL curriculum in biochemistry. Biochem Mol Biol Educ 2017;45:336-42.
Anton NE, Bean EA, Hammonds SC, Stefanidis D. Application of mental skills training in surgery: A review of its effectiveness and proposed next steps. J Laparoendosc Adv Surg Tech A 2017;27:459-69.
Harrison GA, Hillman KM, Fulde GW, Jacques TC. The need for undergraduate education in critical care. (Results of a questionnaire to year 6 medical undergraduates, University of New South Wales and recommendations on a curriculum in critical care) Anaesth Intensive Care 1999;27:53-8.
Lisk K. Examining Curricular Integration Strategies to Optimize Learning of the Anatomical Sciences; 2016.
Lube MW, Borman KR, Fulbright AE, Friedell ML. Retrospective evaluation of residents' American Board of Surgery In-Service Training Examination (ABSITE) scores as a tool to evaluate changes made in a basic science curriculum. J Surg Educ 2010;67:167-72.
Worley P, Silagy C, Prideaux D, Newble D, Jones A. The parallel rural community curriculum: An integrated clinical curriculum based in rural general practice. Med Educ 2000;34:558-65.
Hartling L, Spooner C, Tjosvold L, Oswald A. Problem-based learning in pre-clinical medical education: 22 years of outcome research. Med Teach 2010;32:28-35.
Batool Z, Qureshi RH. Quality Assurance Manual for Higher Education in Pakistan. Pakistan: Higher Education Commission; 2007.
Au W. High-stakes testing and curricular control: A qualitative metasynthesis. Educ Res 2007;36:258-67.
Riley SC, Morton J, Ray DC, Swann DG, Davidson DJ. An integrated model for developing research skills in an undergraduate medical curriculum: Appraisal of an approach using student selected components. Perspect Med Educ 2013;2:230-47.
Mullan JR, Weston KM, Rich WC, McLennan PL. Investigating the impact of a research-based integrated curriculum on self-perceived research experiences of medical students in community placements: A pre- and post-test analysis of three student cohorts. BMC Med Educ 2014;14:161.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]