‘We need one more hour solely based on anatomy… Give us anatomy!’: Early-year learner perceptions of anatomy within an integrated & case-based learning osteopathy curriculum

Abstract

Background

Integrated curricula, where the teaching of basic and clinical sciences is combined horizontally and vertically, have received increasing attention in the health professions education literature. This structure is thought to better prepare learners for the clinical learning environment and their future work as a health professional. Our research aimed to explore student perceptions of anatomy within an integrated curriculum underpinned by case-based learning (CBL).

Methods

Two focus groups using semi-structured questions were conducted with year 1 learners. Audio-recorded data was then thematically analysed through a constructivist lens.

Results

Thirteen students participated. Participants recognized the value of anatomy for their future work and ascribed it a high priority for their learning, including asking for greater anatomy contact hours. CBL does not assist in learning anatomy per se, rather it provides context, enhances its relevance to future work, and unifies the curriculum. With the exception of anatomy and biomechanics, students had trouble recognizing other components of the integrated biomedical sciences subject (e.g. physiology and pathology). This outward disconnect resulted in confusion. However, participants reported strong links between the basic science and clinical skills units.

Conclusions

Study outcomes suggest learners appreciate the integrated curriculum structure in the early stages of their anatomy learning. Its high value may be related to perceived difficulty of this content, or the hidden curriculum privileging anatomy over subject content. Integrated subjects need to balance content to ensure it is reflective of future practice, and signpost to assist learners to navigate the subject and facilitate their learning.

Introduction

Traditional health science curricula are dominated by basic sciences in the early years of a program followed by clinical learning in later years [1,2]. Although such a structure is common and persists in some programs, this approach has been considered to have a number of limitations (e.g. teacher-directed, limited integration of knowledge with clinical work) [2] and curriculum change to address these limitations can be slow. The basic premise of a contemporary health science curriculum is that it should engage learners in contextual learning [2], that is putting the content being learnt into the context of their future work. A curriculum should also engage students as adult learners who are independent problem solvers, rather than encouraging memorization of swathes of biomedical science knowledge. The desired outcome of this contemporary health science curriculum is better integration of clinical and biomedical sciences in the clinical learning years [3,4]. Authors have advocated the use of integrated curricula [3], that is, clinical learning is combined with developing an understanding of the biomedical and social sciences [5]. The integrated curriculum aims to provide context for academic content, improve the learning environment [2], improve learner engagement and content retention.

Medical curricula designers have been drawn to integrated curricula to reduce “… teaching unnecessary detail in basic sciences, including gross anatomy, often to levels irrelevant to clinical practice” however these authors also note that “… the debate on this matter has been speculative or anecdotal, lacking reliable supporting data.” (p. 212) [6]. Removing “unnecessary detail” may reduce contact hours and student load, however the importance of basic sciences, including anatomy, is thought to be at risk with such changes [4,7]. With the introduction of integrated curricula and use of case-based or problem-based learning, anatomy teaching hours have reduced by up to 80% in Australian medical schools, a trend reflected worldwide [6].

Evidence of the effect of reduced anatomy education is often conflicting and tends to focus on problem-based learning (PBL) [8,9] rather than case-based learning (CBL), the focus of the current paper. Problem-based learning is widely used in health professions education. The premise of PBL is that the learner's work through a clinical case presentation as a group. The learner's raise their own questions, explore issues related to the case and attempt to resolve the case in what has been referred to as open enquiry [10]. There is often no preparation required on the part of the learner before participating in a PBL case, and no prior knowledge is required [11]. The educator has a minimal role in PBL, allowing the learners to guide their own discussions and learning, and highlighting aspects of the case for learners to pursue after the session. In contrast, the role of the educator in CBL is more structured – bringing the learners back to the key learning objectives for the case, guiding learners through the case and providing closure. This has been referred to as guided enquiry [10]. CBL also typically includes some pre-session preparation by the learner. Both PBL and CBL are used to develop learners' problem-solving and teamwork skills, in addition to facilitating independent learning, although the more structured CBL approach may be better suited to learners in the early years.

Research into the combination of integrated curriculum and CBL is emerging [12]. Klement, Paulsen [13] reported a 28% reduction in course contact hours yet a 9% increase in the average gross anatomy examination scores. Likewise, Parmar and Rathinam [14] implemented integrated and CBL anatomy sessions that resulted in significant improvements in the long-term knowledge retention and 93.8% of students reporting that this approach enhanced their ability to learn respiratory anatomy.

Much of the research regarding integrated curricula and CBL focuses on its efficacy at producing academic results in comparison to other teaching/learning methods. Of the studies exploring the student perception of integrated curricula, CBL or anatomy teaching many do so using quantitative methods [[14], [15], [16]]). However, this approach may not capture the personal nature of the student experience. A systematic review of CBL in health professional education identified the need for more qualitative research to better understand how CBL helps students learn [5]. Bergman, Prince [17] also identify the student voice as a significant area for evaluation of anatomy education. In response to these calls, the current research utilized a qualitative approach to investigate osteopathy student perceptions of the integrated curriculum and CBL in respect to learning anatomy in the first semester of a pre-professional program.