Integration in medical education is best described by Harden as ‘the organization of teaching matter to interrelate or unify subjects frequently taught in separate academic courses or departments’ ‘(Harden et al, 1984) [1]. Shoemaker also defines an integrated curriculum as "education that is organized in such a way that it cuts across subject matter lines, bringing together various aspects of the curriculum into meaningful association to focus upon broad areas of study" [2].

Undertraditional curriculum in India, majority of the medical colleges teach subjects in isolation without much effort to integrate the basic/paraclinical with the clinical subjects. An integrated curriculum provides a platform where learning takes place in a context (contextual learning). It also promotes a holistic approach to patients and their problems. The learning theory ‘constructivism’ behind the integration of basic and clinical sciences states that learner needs to understand the concepts in basic sciences and make connections with its applicability in clinical sciences. There should be development of construction of understanding the relevance of learning basic sciences [3].

In this review, we will discuss, how to develop, implement and evaluate an integrated curriculum. Let us start by reviewing the importance of integrated curriculum and why it is the need of the hour.

Knowledge is most effective when the organization of that knowledge matches the way in which the knowledge is to be used [4]. It is believed that the current system of medical education is fragmented, the subjects are taught in isolation with unnecessary repetitions and there is no structured or systematic effort to interrelate the concepts of various diseases [5,6]. For example, when students are taught about liver in different disciplines without any integration, they may develop the concept of anatomical liver, physiological liver, pathological liver and so on without getting the holistic concept of the body and various diseases in the context of liver. As a result, it is left to the students to understand or develop the correlation between the topics taught in various disciplines.

Human body is a perfect example of integration. The knowledge learnt in isolation remains to be applied to a complex system like human body. The basic idea of integration is to develop a holistic approach to treat that particular disease affecting human body. It is true that body is divided into systems and organs but they always work in unison with highest level of coordination possible. Similarly, it is important to have coordination between subjects to understand the body and the diseases better, so that when a student sees a patient, it should all come together.

An integrated approach in medical education captures students’ attention and creates more excitement in learning, prevents repetition, enhances reinforcement of important areas or topics, and improves retention of learning [7]. The long-pending demand of students that basic and clinical sciences should be integrated can be achieved with this approach. Basic sciences’ role is well documented for learning of clinical sciences [8]. The students trained with such an integrated curriculum, make more accurate diagnosis than students trained in a conventional curriculum as they learn to apply their knowledge to clinical practice as a result of more contextual learning. This promotes a holistic approach to patients and their problems. It also promotes interdepartmental collaboration and helps in rationalization of teaching resources [9,10]. It was interesting to note that in various workshops conducted at various medical colleges, few faculty members got introduced to each other for the first time; although, they had been working in the same institute for long.

Here, it is important to understand that in our body, each and every cell, every tissue, organ and system has its own importance and they need to develop fully for any kind of coordination to be successful. Similarly, each and every discipline or subject is important and should also have their identity maintained but never in isolation. It is just like a rainbow where the different colours maintain their identity but are very closely assimilated to showcase their features. The impact of a rainbow is different than the single colours. In medical curricula also there has to be a balance between integrated teaching and discipline-based teaching.

Integration has traditionally been divided into three types based on two basic components of curriculum as reference points that is time frame and clinical disciplines/ subjects [11].

Horizontal Integration: Integration that occurs across disciplines/subjects but within a finite period of time. For example, integration among subjects of first phase of undergraduate curriculum in India. (Fig. 1a).

Vertical Integration: Integration across time – it breaks the traditional divide among the basic science and clinical subjects and brings them together. For example, integration among subjects of different phases (Fig. 1b)

Spiral Integration: This is the integration across time and disciplines. It is the most complete form combining both horizontal and vertical integration. The major advantage of this model is the better reinforcement of topics through a natural progression from simple to complex using a curriculum that breaks down the barriers and boundaries between the courses and the departments [12] (Fig. 1c).

Fig. 1 (a) Vertical Integration; (b) Horizontal Integration; (c) Spiral Integrated model

Over the last few decades, medical educationists have realized the importance of integration and understand that integration is a key factor in the delivery of an effective educational program [9]. The two most discussed models for the development of integrated curriculum are the ten ways to integrate Curriculum by Robin Fogarty [13], and the integration ladder by Harden [14].

We have tried to compare and correlate these two models for better understanding and simplification (Table I and web table I).

Table I Comparison of Two Common Models of Integration

Two integrated teaching models given by Fogarty which are not correlating with any of the steps of Harden ladder are the threaded model and the networked model. The threaded model of integration thread various concepts and skills throughout various disciplines. Teaching sessions are planned according to the identified skills or concepts. In the networked model, the learners themselves, knowing the intricacies and dimensions of their field, can target the necessary resources as they explore within and across their areas of specialization [13]. For example, the option of selecting electives in a course. Students chooses their own areas of interest and during the electives, he or she may come across number of experts in the field and develop the networking.

The difference between integrated curriculum and integrated teaching is almost similar to the difference between syllabus and curriculum. Integrated teaching is limited to one particular session or topic which can be achieved either by individual efforts or collectively by the concerned departments, while integrated curriculum requires effort at larger level, mostly institutional with multiple sessions of integrated teaching. Nesting, the fourth step in the Harden ladder is an example of integrated teaching while the temporal coordination, the fifth step in the ladder is not an integration in true sense as there is no connection between the subjects or the topics, they merely are aligned together. Actual curricular integration starts from the seventh step i.e., Correlation. Integrated teaching is an all or none phenomenon, either it is integrated, or not integrated while integrated curriculum is a continuum from incomplete to complete.

This is usually documented during the development of curriculum whether all the teaching sessions will be integrated or a particular percentage of the curricular delivery will be integrated. Medical Council of India (MCI), in their recent revision of curriculum, have suggested that at least 20% of the curriculum should be integrated and they have also provided examples of the areas where integration can take place [17].

Integration is represented as a continuum with full integration at one end, discipline-based teaching at the other end, and intermediate steps between the two extremes [18]. Integrated curricula can also be labelled as complete or incomplete. Horizontal and vertical integration are examples of incomplete integration while spiral integration is an example of true or complete integration.

The change from traditional subject-based curriculum to an integrated curriculum should be gradual and starts with the understanding of one’s place in the integration ladder. Most of the teachers agree with the value and importance of integration but are not sure about the extent of integration required and how to go about it. The institution should take into consideration the existing curriculum, experience and training of the teachers, existing infrastructure and most importantly the aim of the curriculum, before deciding on the level of integration. The higher one moves up the integration ladder, the greater coordination and communication is required amongst different disciplines [14].

Before actually going for its implementation, it is important to understand that integrated teaching or curriculum is the integration of the concepts where various subject based knowledge or aspects of one theme or topic is assimilated to provide the holistic approach. Integration does not mean that multiple teachers from different subjects are delivering their lectures in the same session. Planning of the session is usually done before the actual teaching session by subject experts/ teachers about the content and delivery methods. It is not always necessary to actually involve the teachers of different subjects during the teaching sessions; they are mostly involved at the planning level only. However, if you think that getting a surgeon into anatomy class can encourage/motivate students to learn anatomy in context, then that can be done.

There are many challenges in developing and implementing integrated teaching in a curriculum. These include lack of will, lack of good leadership support, inadequate infrastructure/resources, prefixed mindsets, and faculty resistance due to fear of more work. There are many myths associated with integrated curriculum like multiple teachers will be required for one integrated session, integrated curriculum will create more confusion, department will lose its identity and faculty will lose its importance in discipline-based compartments etc.

However, the challenges provide opportunities to innovate and experiment with various models of integration and evaluate their utility in the Indian context, especially in the new curriculum.

Integration in medical education is the need of the hour as we move towards holistic healthcare. The two main models of integration given by Fogarty and Harden are compared and commonalities discussed for better understanding of the concept. The various levels and models of integration provide a lead to innovate more in integrating the disciplines for better contextual learning. Integration can be implemented from the early years of the undergraduate teaching, and higher level of integration is possible as the learners progress through the course. The process of change from conventional to new integrated curriculum is difficult, yet achievable, and requires robust planning and coordination amongst the medical educationists at all the levels.

Acknowledgement: Dr Fatimah BV for designing the figures.

Contributors: All the authors were involved in reviewing the literature and preparing the article.

Funding: None; Competing interest: None stated.

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