|LETTER TO THE EDITOR
|Year : 2014 | Volume
| Issue : 2 | Page : 221-222
A need to climb high to integration ladder
Nazish Fatima1, Syed Muhammad Faizan Ul Haque2
1 Department for Educational Development, The Aga Khan University, Karachi, Pakistan
2 World Health Organization, Polio Eradication Initiative, Karachi, Pakistan
|Date of Web Publication||31-Oct-2014|
DG-1 ARC Towers, Stadium Road, Karachi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Fatima N, Ul Haque SF. A need to climb high to integration ladder. Educ Health 2014;27:221-2
Integration is now more widely accepted as a feature of all programs; hence the integrated curricula have been implemented by a growing number of medical schools all over the world, including schools based in industrialized and developing countries.  Integration in the curriculum demands effective leadership and a robust department of medical education, with a team of qualified medical educationists. Inspired by international and regional changes in medical education, The Pakistan Medical and Dental Council of Pakistan (PMDC) and the Higher Education Commission (HEC) of Pakistan introduced major reforms in medical education to meet health needs and expectations. This has sent a wave of curricular reforms throughout the country.
The PMDC regulations for the MBBS degree states that: "With the information explosion of the last century and scientific discoveries expanding the boundaries and restructuring the concepts of current knowledge, it is essential to work towards curricular integration".  Following the guidelines of the PMDC, a few medical schools have actually taken steps toward integration, including development of the department of medical education, faculty training programs, and collaboration among departments. Yet, despite the need and wake-up call, many medical schools here are still facing difficulties in the development of an integrated model even at basic levels, with the schools remaining traditional places of learning.
One of the reasons for this is the lack of effective government oversight of private medical education, which has led to the proliferation of medical schools. In our estimation, medical education in Pakistan has faced major decline during the last six years due to recognition of mostly substandard medical institutions. This huge profit-making business has expanded the number of private medical colleges to 90, an enormous increase in less than six years. This growth in medical schools is one of the high profile issues that confront undergraduate medical education in Pakistan.
There are other concerns as well. Many medical colleges have been given license to increase their number of admissions per year at high rates. Additionally, the Department of Medical Education has ignored trends in the shortage in the workforce of educationists. Qualified medical educationists have left the country in search of better prospects, with negative consequences for medical education departments in the country's medical schools. In many medical colleges, there is no department of medical education or, if there is, there is a single medical educationist, who may or may not be qualified to run the program alone.
In most medical institutions in Pakistan, department heads have complete control, which can lead to an individual-centric system and a curriculum driven by one person alone.  Consequently, the curriculum is segregated into disciplines. The individual-centric system tends to be pluralist rather than an integrated unity. In a majority of medical schools, the discipline-curriculum is organized in such way that basic science subjects are studied in years 1 and 2 and then never revisited formally in the following three clinical years, resulting in a significant decline in basic science knowledge.
We contend that decisions regarding the curriculum should be based on the relevance of the topics to the needs of the graduating physician, not on the perceptions of the departmental faculty alone. Discipline boundaries hinder the collaboration among departments. Contributing to the problem, the process of change is difficult, especially in those public sector institutions with established curricula, where it requires changing the mindset of the faculty members at senior levels. Faculty resistance is one of the contentious issues in implementing any significant change in these institutions.
There are several medical schools in Karachi that are still unaware of the process of integration and appear to find it difficult to design and implement an integrated curriculum due to lack of knowledge and training on the subject. In medical schools where the integrated curricula is not a high priority, teaching plans and assessment methods are not designed to enhance integrated learning. In most institutions, there is no committee or regulatory body to take responsibility for the curriculum.
One of the first and most essential approaches that schools should pursue is to identify the international standards of integration in curriculum design and then determine the gaps in their existing curricula. Another important step toward integration is human resource development for the change process. Need-based training programs should be designed to familiarize faculty with the advantages, objectives and development of an integrated curriculum.  Integration of the curriculum is not the responsibility of one person but requires involvement of staff from different departments and other key stakeholders. Each discipline needs to map their curricular content in interdisciplinary settings.  In this regard, it is vital to formulate a "Curriculum Committee" consisting of senior faculty members that should be led by a qualified medical educationist.
While it is ideal to switch to a whole new integrated curriculum, overly ambitious undertakings should be avoided. Begin with modular integration. For this purpose, Modular Integration Committees (MIC) may be formed, led by a module coordinator for every committee. Each committee will be comprised of representatives from different departments including clinical teachers and a medical educationist.  Integration must be incorporated into the assessment process as well.
In addition, the organizational reward structure must include incentives that recognize participation by the faculty in innovation in curriculum development. Interpersonal respect, support, collaborative problem-solving and skillful conflict resolution accelerate the curricular change process. In order to minimize faculty resistance, a change-conducive environment is essential. 
Although medical educationists have realized the need for integrating basic and clinical sciences to eliminate sharp discipline boundaries, it is difficult to switch to this system without understanding its process, infrastructure and faculty support. Hence, medical schools should fulfill these requirements according to their resources and, in turn, emphasize higher levels of integration. There is no doubt that the standard of medical education has been compromised, not only in the private but in the public sector, hence the PMDC as the regulatory body should continuously monitor the implementation of innovations in medical and health professions schools in Pakistan.
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