Continuing our examination of Harden’s SPICES model (1), the I represents the spectrum from integrated teaching to discipline-based teaching. Harden states that “integration is the organization of teaching matter to interrelated or unify subjects frequently taught in separate academic courses or departments.” In more traditional medical or chiropractic educational programs, the teaching tends to emphasize classical disciplines, such as physiology, anatomy, chiropractic adjusting or radiology. The clinical exposure to patients tend to occur late in the curriculum; for example, when I was a student at the then National College of Chiropractic, I did not see my first patient (either for examination, observation or otherwise) until I began my 9th trimester of 10. The standard program organization of a traditional program is one where these foundational discipline-based courses are used as building blocks for later courses which hone the information that follows.
But we have now see movement toward integration across and through the curriculum. Instead of working in sequence only, chiropractic programs are beginning to be both vertically and horizontally integrated. Horizontal integration is integration between parallel disciplines, such as anatomy and physiology, or diagnosis and chiropractic adjusting. An example would be a course in the gastrointestinal system, in which the student learns not just the anatomy of the GI system, but its concomitant physiology and biochemistry. This course is taught not just by a single PHD anatomist, but multiple teachers from several disciplines. Vertical integration occurs when there is integration between disciplines traditionally taught in different phases of the curriculum; thus, courses early in the curriculum are integrated with courses that occur much later in the program. Here, you might see students placed into small groups for the purpose of focusing on patients with chronic disease, and over the course of a 2-year period they would apply the knowledge they learn from their coursework to the understanding of the problems facing those chronic patients. Finally, it is common for programs to incorporate elements of both vertical and horizontal integration.
Harden notes several reasons to use integration in curriculum planning and development. (1) It helps reduce the typical fragmentation of medical or chiropractic courses. It provides a better sense of the unity of information involved in health care education. (2) It can help motivate students and shape their attitude. Integration prevents students from feeling that they are becoming anatomists or physiologists, that the basic sciences are something to get through. They begin to see the relevance of these disciplines to the general practice of chiropractic. (3) It can help improve the educational effectiveness of teaching. They learn better, integrate information better, and therefore forget far less than would occur in a strict discipline-based approach. (4) It fosters higher level objectives. There is less emphasis on recall, more on integration of knowledge. (5) It promotes faculty communication and collaboration. Faculty members from different disciplines are brought together and work together to provide training.
There are also factors that support the use of a discipline-based approach. (1) This approach ensures that the content and fundamentals of a discipline are not neglected. Sometimes information does get lost in an integrated approach. (2) There can be omission of topics. An integrated approach is a systems-based approach, and without proper monitoring, topics can be lost. I saw this at National College after it moved to a problem-based approach; somehow, the entire unit on managing disc prolapse had been lost and only later was added back in. (3) Better teaching- ownership is important, and many teachers are more enthusiastic when they work in their own discipline solely. (4) Discipline-based teaching is less costly. It requires less planning and oversight. (5) teachers are more comfortable in a discipline-based approach.
In general, I think the chiropractic profession has moved toward a more integrated approach, but retains significant amounts of discipline-based teaching. We need to begin gathering more data to see which system works best.
1. Harden RM, Sowden S, Dunn WR. ASME Medical Education Booklet No. 18. The SPICES Model. Med Educ 1984;18:284-297