Spiral Integration in Pharmacy Education

by Hanson Walker, Pharm.D., PGY1 Community Pharmacy Resident, University of Mississippi School of Pharmacy

As new medications, therapies, and healthcare practices are constantly evolving, there is an increasing need to develop a curriculum that allows students to not only acquire foundational knowledge but also learn how to most effectively put this knowledge into practice.  Pharmacy and other health professional schools must constantly evaluate and adapt their curricula to best fit both the volume and breadth of information that must be disseminated and the changing learning preferences of each new generation of learners.  Changing an entire curriculum is certainly a major undertaking; however, it can be accomplished using principles of curricular design.

While learning often occurs by starting with the most foundational information and building towards the full scope of knowledge needed by a practitioner, when designing a curriculum one must start with the end in mind and reverse the process (aka backward design).  If we start with a long list of all the discrete bits of knowledge a healthcare professional needs to know and attempt to incorporate them as we move forward in the curriculum, the result will be a disheveled mess with no demonstrable flow and likely poor learning outcomes. On the other hand, if the overall structure is established at the inception of the curriculum, deciding first what the practitioner must be able to do, and then assembling the bits and pieces that together form the profession’s knowledge base, it can then be integrated throughout the curriculum.  But how? How can we best integrate the plethora of information into a cohesive whole that prepares students for their future careers?

Integration of knowledge has long been a goal of curriculum developers, and this integration has historically occurred across two dimensions.  The first, horizontal integration, includes multiple topic areas (for example, pharmaceutics, pharmacology, medicinal chemistry, pharmacotherapeutics) whereby instructors deliver material related to the topic (e.g. a disease state) in parallel.  Thus similar-level material in each of the subjects is taught concurrently.  This approach can take many forms ranging from multidisciplinary (each discipline works separately), to interdisciplinary (commonalities between disciplines are leveraged to reach a common understanding of a topic), and transdisciplinary (disciplines are so interwoven as to be nearly indistinguishable).  The second, vertical integration, involves the introduction of increasingly complex material across time, where students are presented with basic, foundational knowledge and concurrently introduced to related clinically-oriented foundational experiences in order to bridge the gap between theory and practice.  The complexity of theory and practice experience build over time.  Spiral integration fuses these two concepts together.

In spiral integration, horizontal and vertical integration are merged to form a metaphorical spiral.  In theory, basic concepts are revisited with increasing complexity at various touchpoints throughout the curriculum.  This allows new knowledge and ideas to be correlated with previously learned concepts.  But, there are challenges to the implementation of such an approach. Overcoming these challenges requires both foresight by the curriculum designers and effective implementation by the faculty.

Let’s take a look at a concrete example of how spiral integration might be implemented.  At its core, spiral integration is basically a curriculum structure that involves the layering of concepts from multiple disciplines, with the complexity of the information increasing with each passing year.  In this type of curriculum, basic and clinical sciences are interwoven from the beginning, allowing the student to understand the relationships between pharmaceutics, medicinal chemistry, pharmacology, pharmacotherapeutics, as well as the social and administrative sciences.   Let’s take a closer look at how a specific instructional approach could be spirally-integrated.  Problem-based learning (PBL) is a common teaching methodology within healthcare education, and, like many other educational strategies, it can be used throughout a spirally-integrated curriculum.  PBL cases would be used beginning in the first year of pharmacy school, yet these cases would not focus heavily on therapeutic knowledge that the students have yet to develop but rather on social determinants of health, nonadherence, and healthcare communication.  In this way, students are introduced to some foundational concepts without being overwhelmed by the breadth of knowledge expected of a pharmacist.  Once students progress to the second year, concepts related to therapeutics would be included in patient cases, while reinforcing previously covered concepts learned within the curriculum.  During the third year, students would be given increasingly complex cases with greater emphasis on more complicated aspects of care.  Finally, in the last year of the curriculum, students progress from the fabricated cases to the real-world experiences (aka advanced practice experiences), where all of the knowledge they have gained is put into practice.

Given the seemingly clear benefits of a spirally-integrated curriculum, it would seem that this type of structure would basically be educational canon, but it is not without controversy.  Detractors may argue that while there is significant theoretical value for spiral integration, there is little evidence to support its effectiveness.  This is at face value a true statement, but it is nonetheless a misleading one, as the lack of evidence is in large part due to the difficulty of performing such a study rather than any substantial reasoning or evidence against the concept.  On the other hand, evidence shows that students in an integrated curriculum exhibit heightened retention of foundational information and improved application of learned material to real-world practice.  Due to this combination of theoretical soundness and evidence (albeit limited), integration across domains of knowledge with increasing complexity over time increases our chances of producing graduates ready to enter the workforce as well-informed, competent practitioners.

References

Rockich-Winston N. Toward a pharmacy curriculum theory: spiral integration for pharmacy education. International Journal of Medical Education 2017;8:61–2.

Husband AK, Todd A, Fulton J. Integrating science and practice in pharmacy curricula. Am J Pharm Educ 2014;78(3):Article 63. 

Pearson ML, Hubball HT. Curricular integration in pharmacy education. Am J Pharm Educ 2012;76(10):Article 204.

Schwartz AH, Daugherty KK, O’Neil CK, et al. A curriculum committee toolkit for addressing the 2013 CAPE outcomes. Curriculum SIG Writing Group. 2014.