While much has been written about integration and education, little in the literature is specific to veterinary medicine. However, the fundamentals of how students learn and how curricula are designed and implemented are similar regardless of the situation. This chapter will discuss integration in the context of medical education and conclude with a short section on integration and veterinary medicine. Most veterinary school curricula today follow a traditional medical school design, in which two years of basic and paraclinical (foundational) sciences are followed by two years of clinical (applied) sciences. Courses in the first two years are usually discipline based, delivered independently, and include subjects such as anatomy, embryology, neuroscience, histology, physiology, biochemistry, microbiology, pharmacology, and pathology. The effectiveness of this traditional approach in medical education has been questioned in recent years, resulting in a call for integration of the basic sciences with each other as well as with the clinical sciences (Cooke et al., 2010). This chapter defines integration, provides support for why integration is a good strategy for a learner, describes approaches to integration and how a session, course, or curriculum could be integrated, and discusses how integration affects assessment. It concludes with the reported benefits and challenges of integration and a short section on integration and veterinary medicine.

While there are a number of definitions in the literature, most start with the dictionary and define integration as combining two or more things to make something more effective, more harmonious, or more coordinated, often by the addition or rearrangement of elements (Achike, 2016; Schmidt, 1998).

When applied to teaching, Harden defined integration as “the organization of teaching matter to interrelate or unify subjects frequently taught in separate academic courses or departments” (Harden, Sowden, and Dunn, 1984).

When applied to medical education, integration refers to situations in which knowledge from different sources (basic science, clinical, factual, experiential) connects and interrelates (Regehr and Norman, 1996) in a way that fosters understanding and performance of the professional activities of medicine (Kulasegaram et al., 2013).

Some writers believe that a very precise definition is necessary to aid in designing, implementing, and reviewing integrated curricula and integrated curricular units (Brauer and Ferguson, 2015). Utilizing the spiral model as the ideal goal, they propose that an “integrated curriculum” be defined as “fully synchronous, trans-disciplinary delivery of information between the foundational sciences and the applied sciences throughout all years of a medical school curriculum.”

Others refer to an integrated curriculum as interdisciplinary teaching, thematic teaching, and synergistic teaching (Malik and Malik, 2011).

In this chapter, integration is discussed in its broadest context: within learning sessions, within courses, and within programs.

Many aspects of veterinary education are modeled after medical education. The traditional curricular design of two by two harks back to the first call for reform in medical education (Flexner, Carnegie Foundation for the Advancement of Teaching, and Pritchett, 1910). Flexner had observed that most medical schools relied on lectures to transmit information to students and he contended that this passive form of learning was ineffective if it was not connected to practice. He argued that a better model was to apply knowledge through more active forms of laboratory and clinical experience, providing opportunities for integrated learning (Irby, Cooke, and O’Brien, 2010). Flexner naively assumed that students would be able to apply what they learned in the class and the laboratory to the bedside. This fundamental model of education continues today in many medical schools and most veterinary schools and recently, 100 years after the first call for reform, a second call by the Carnegie Foundation was issued. The key findings (Cooke et al., 2010) recommended four goals for medical education for the future: standardization and individualization; integration; insistence on excellence; and formation of professional identity. The specific recommendations for integration included:

• Connect formal knowledge to clinical experience, including early clinical immersion and adequate opportunities for more advanced learners to reflect and study.
  
• Integrate basic, clinical, and social sciences.
  
• Engage learners at all levels with a more comprehensive perspective on patients’ experience of illness and care, including more longitudinal connections with patients.
  
• Provide opportunities for learners to experience the broader professional roles of physicians, including educator, advocate, and investigator.
  
• Incorporate interprofessional education and teamwork into the curriculum (Cooke et al., 2010).

Rather than leaving integration to chance, the report called for medical schools to implement integration actively throughout all levels of the curriculum. Such integration would allow medical students to appreciate the relevance and clinical context of information encountered in the classroom, to build experiential knowledge to complement formal knowledge, to transfer and apply formal knowledge to the clinical setting, and, ultimately, to be better prepared for the complex tasks involved in patient care (Dyrbye et al., 2011).

Integration, as a fundamental requirement of medical school curricula, has also been advocated by those who oversee education in Canada (Bandiera et al., 2013) and the United Kingdom (GMC, 2015).

If integration is to be used as an effective learning strategy, then integration must focus on the learner (see Box 5.2). It should be looked at as a cognitive function that occurs within the learner as the learner links clinical concepts with basic science.

Students in a classroom generally organize medical knowledge according to the structure of the curriculum. For example, if pathophysiology is taught according to organ systems, then the student’s knowledge will be similarly organized, and the retrieval of information will be triggered by questions related to a specific organ system or to the context in which the material was taught. However, in the clinical setting, wellness and disease are the focus. Clinical problems cross organ systems and disciplines and so the transition for the student from preclinical to clinical is awkward and difficult (Bowen, 2006). Only after learners make new connections between their knowledge and specific clinical encounters can they also make strong connections between clinical signs and the knowledge stored in their memory. Integrating information in teaching sessions, courses, or across the curriculum and helping students make the connections between prior knowledge and new knowledge, especially in the context in which they will use this information, will provide students with opportunities for meaningful and relevant storage and retrieval of information.

The earlier that students begin to accumulate a mental database of cases, the sooner they will develop a firm foundation on which to allow nonanalytic processes to contribute to the development of clinical reasoning. Context specificity and the need to build an adequate database from which to reason by way of analogy demand that many examples be seen, that students actively engage in the problem-solving process, and that the examples provide an accurate representation of different ways in which specific diseases present (Eva, 2005). Using comparisons of clinical examples can help students identify deep features of basic science concepts that will assist them in elaborating on that knowledge as they progress into clinical education (Woods, Brooks, and Norman, 2005).

The benefits of integration are attributed to presenting information and problems in a way that mimics how they are encountered in the real world, and presenting facts in relevant, meaningful, and connected ways. The responsibility for learning resides with the learners, who must construct their own meaning, and hence integrate, from available learning opportunities. Cognitive psychology has demonstrated that facts and concepts are best recalled and put into service when they are taught, practiced, and assessed in the context in which they will be used (Bransford et al., 1999). Since the ability to perform thinking tasks is related to success in retrieving relevant knowledge from memory, educational strategies should be directed at enhancing meaning, reducing dependence on context, and providing repeated, relevant practice in retrieving information (Regehr and Norman, 1996).

For new information to have meaning, it must be integrated into the semantic network, an elaborate set of connections between abstract concepts and/or specific experiences. These linkages between concepts and experiences are based on meaning. By linking basic science material to clinical problems, often through patient- or case-based learning, students are able to integrate the material into their existing networks for better retrieval. Likewise, clinical reasoning skills should be taught with clinical content, as the two must be integrated in the development of expertise (Regehr and Norman, 1996). The context in which we teach information also affects the ability to retrieve that content later. Retrieval depends on the similarity between the context or condition of retrieval, and the context or condition in which the item was originally learned. Thus, teaching students about basic science in the context of clinical examples and explicitly making connections are ways in which integration can enhance long-term retention and deeper understanding. Finally, practice is vital to the development of expertise. The work on the specialization of routines suggests that individuals must practice the same problem-solving routines repeatedly. In addition, the novice must have extensive practice in identifying the situations in which a particular problem-solving routine is likely to be useful.

The use of authentic learning, connecting knowledge to real-world issues, problems, and applications, is a powerful learning strategy. Adult learners prefer meaningful learning: they learn best when they understand the topic’s relevance and how it can be immediately applied to current relevant problems. Thus, students are more likely to be interested in what they are learning, more motivated to learn new concepts and skills, and better prepared to succeed in careers, if what they learn mirrors real-life contexts. This then equips them with practical and useful skills and addresses topics that are relevant and applicable to their lives outside of school. Another principle of authentic learning is that it mirrors the complexities and ambiguities of real life.

Therefore, when examining integrated learning from the learners’ perspective, the following are important considerations (Prideaux, Ash, and Cottrell, 2013):

• Learners can achieve integration from constructing learning in real work settings.
  
• Learning will be facilitated when there is integration of content beyond the single context into multiple contexts, and when the learning contexts are similar to those in which information must be retrieved.
  
• Integrated learning should be holistic rather than atomistic.

While there is ample indirect evidence that integration enhances memory and retrieval and therefore facilitates thinking tasks, there is little direct evidence. One example involves the use of progress testing in a contextual medical curriculum with integration of the basic and clinical sciences. The change to this type of curriculum was reported to lead to a more gradual, steadier, and finally higher level of mastery of clinical knowledge. At the same time, the study showed that a stronger emphasis on the basic sciences in the early years of a curriculum led to a steeper learning curve in the mastery of clinically relevant basic knowledge. This type of knowledge continued to develop, even without formal teaching in this domain, during the later years of the curriculum (van der Veken et al., 2009).

Within a curriculum, there are a number of ways to approach integration. The two main types of integration are integration through dedicated approaches and integration through specific contexts (see Box 5.3). In the first of these, the program is deliberately structured to organize or facilitate learning across the disciplines through the use of key concepts, themes, or problems. Within this, integration is referred to as horizontal or vertical or both.

Integrated learning through context is commonly found in clinical settings. Community, ambulatory, primary care, and general practice settings offer excellent opportunities for integrated learning in current veterinary school curricula, providing students with chances to gain entry-level knowledge, skills, and behaviors.

While educators can provide integrative opportunities within the curriculum through either dedicated approaches or specific contexts, this will not necessarily translate into integrative learning. Integration should always emphasize the cognitive activity that occurs within the learner.

In an integrated curricular model, the underlying principle is synthesis or blending. Instead of individual subjects or disciplines dominating a curriculum, there tends to be themes that draw on different subjects or disciplines, and these run longitudinally throughout the year or the entire curriculum. In this way, students are encouraged to see the links between subjects or disciplines and to understand how subject- or discipline-based knowledge is applied to real-world cases. With the shift to more integrated curricula, there are also other shifts such as weak framing (Loftus, 2015). This is because there are many ways of implementing pedagogy; for example, problem-based learning sessions can be dovetailed with traditional lectures and laboratories.