If medical education aims at deep understanding of concepts, development of competencies, and application of knowledge, new learning modalities should be introduced. Over the last three decades several changes have been introduced to medical education worldwide. These changes were initiated in response to several declarations including the General Medical Council “Tomorrow’s Doctors” , the Australian Medical Council [2–4], the Association of American Medical Colleges (AAMC), and the National Commission for Academic Accreditation & Assessment . The aims of these recommendations are: making more emphasis on concepts and principles and moving from an overloaded medical curriculum, introducing integration across basic and clinical sciences, enhancing application of knowledge, and changing examinations from focusing on memorization of factual knowledge to testing competencies, cognitive skills, application of knowledge, and deep understanding .
King Saud University (KSU) College of Medicine, a leading medical college in Saudi Arabia, has introduced a hybrid problem-based learning (PBL) into the preclinical years. These changes commenced in the academic year 2009/2010. The rationale for the changes introduced in the medical curriculum are (i) a traditional curriculum may enables students to understand basic sciences such as anatomy, physiology, pathology, pharmacology etc., but does not prepare students for the clinical years and learning in a clinical environment, (ii) the explosion in medical/health information and the rapid progress of research and discoveries necessitates that medical curricula focus on learning approaches that enhance student’s self-directed learning, and life-long learning, (iii) medical workforces are looking for doctors who are competent, and have acquired knowledge, skills, and professional attitude required for clinical practice; an established traditional curriculum usually focus on acquisition of medical knowledge and memorisation of facts and therefore does not prepare graduates to fulfil the needs of the medical workforce, and (iv) medical graduates usually travel seeking postgraduate education and clinical practice in other countries, therefore good universities are usually interested in reshaping their curricula to meet international standards and contribute to the profession. Based on these changes, the college adopted changes that are based on best practices and evidence from medical education research.
KSU College of Medicine accepts students after completing a one-year course comprising subjects such as biology, chemistry, physics, medical biostatistics, and English for medical profession. Only students with a grade point average (GPA) higher than 3 are accepted .The new medical curriculum strongly emphasizes the importance of small group learning, problem-based learning, self-directed learning, enquiry-based learning, use of e-learning, and hands-on training in clinical skills lab, as well as practical classes. While some medical schools choose to cluster PBL cases around themes such as “oxygen delivery”, “disturbed consciousness”, “life cycle” etc. with less strict boundaries to body systems , The curriculum development unit decided to organize the PBL cases around parallel body systems [9, 10] with the opportunity for students to revisit such themes and build on them from cases allocated to different body systems . In the medical program, the preclinical years are represented in the first two years where disciplines are integrated in a block/module system. The blocks in these two years are: Foundation block, Musculoskeletal block, Respiratory block, Cardiovascular block, Renal block, Nervous System block, Gastrointestinal and Haematology block, Endocrine block and Reproduction block. The remaining three years revolve around various clinical clerkships, and preparation of students to join the medical workforce. To achieve these goals, a new department for medical education was established in 2009, with five specialized units: curriculum development unit, assessment and evaluation unit, clinical skills unit, research and dissemination unit, and Information technology unit. These units work together in harmony with the other 19 departments in the college of medicine to design and implement the new medical curriculum.
Laboratory classes offer an opportunity for enforcing learning and complementing other teaching modalities such as problem-based learning (PBL), lecture, self-directed learning, and e-learning. While PBL and lectures usually focus on the big picture, laboratory classes facilitate learning about details and hands-on experiences. Ideally laboratory classes should parallel the changes introduced to the curriculum-enable students to apply knowledge learnt, discover relationships, conduct laboratory procedures, and end with a meaningful learning [12–14].
Rationales for ILCs
The changes introduced to certain practical classes are a direct response to students and staff difficulties with the understanding the role of preclinical laboratory classes in an integrated curriculum and how these classes should address student’s learning needs in an engaging manner. The ILCs aimed at replacing certain practical classes in which students investigated a concept using the microscope, laboratory animals, or laboratory procedures . In most schools using traditional laboratory classes, students are given a laboratory guidebook in which the procedures are precisely described, and students merely follow the guidebook without thinking deeply [13, 14]. With the changes introduced to laboratory classes worldwide, to reduce animal experimentation, these classes were replaced by class demonstrations and then by a video showing an experiment conducted in a class. These changes limited the value of laboratory classes and encouraged passive learning [12, 15]. In the meantime, knowledge and skills learnt from each laboratory class such as biochemistry, pathology, and microbiology were discipline-based and did not enable students to examine integration of such skills or correlate learning outcomes from such classes to clinical applications. There is no doubt that these classes were useful in assisting students to develop their experimental techniques, observational skills and laboratory skills. However, traditional practical classes were not successful in assisting students to understand application of knowledge learnt and realize the value of basic sciences in clinical investigations conducted for clinical diagnosis of diseases. Also non-integrated classes did not bridge the gap between what students learn from problem-based learning tutorials, lectures, and small group tutorials with desired laboratory skills. Therefore, in the development process of these ILCs, an important starting point was the realization that preclinical classes need to be student-centered, address the outcomes of the curriculum and match with the changes introduced in the curriculum. However, not all practical classes can be integrated due to the nature of their contents and educational objectives. Such practical classes were left as discipline based classes.
ILCs target students’ learning needs
In the early stages of designing the ILCs it was decided to identify the learning needs of the students. Our analysis of students’ performance in year 1 examinations (midblock and the end of the block examinations) showed that students have difficulties in integrating knowledge and applying knowledge learnt to clinical situations. Skills in areas such as interpreting laboratory results and using the findings to refine their hypotheses and correlate biochemical changes with likely pathological and microbiological changes were deficient. Students also experienced difficulties in understanding concepts such as pathogenesis of diseases and signaling sequences of biochemical changes that could end in pathological changes. Such deficiencies and learning difficulties highlight the needs for further training in applying knowledge learnt and correlating microbiology, biochemistry and pathology to clinical situations. The analysis also helped us to select task-based and student-centered approaches in developing these laboratory classes with an emphasis on cognitive outcomes, procedural skills and application of knowledge. This analysis forms the basis on which we introduced the ILCs to fill the gap in the curriculum and help students to overcome these learning difficulties.
With the introduction of the ILCs it was necessary to assess the impact of these classes on students’ learning. To assess the impact of a new teaching/learning modality on student’s learning, it may be necessary to assess short- and long-term retention as well as feedback provided by the learners on their experience [16–18]. For example, in what way has the new teaching/learning modality helped them, has these classes added to their learning experience, and learner’s suggestions for further improvement of such modality. Therefore, this paper aims at outlining the development and implementation of four integrated laboratory classes (ILCs) at King Saud University College of Medicine examining whether core concepts addressed in these classes were learned and retained (on short and long-term bases) and how the students perceived the learning new modality.