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Implementing integrated curriculum in advanced teaching in the fundamentals of homoeopathy utilising flipped classroom, case-based learning, and group discussion: Post-graduate homoeopathic education
, Sonam Ashishkumar Tiwari Mishra2, Anand Ramchandra Kapse3, Kumar M. Dhawale4
*Corresponding author: Dr. Bhavik Ramesh Parekh, Department of Homoeopathic Materia Medica, Dr. M. L. Dhawale Memorial Institute, Palghar, Maharashtra, India. drparekhbhavik@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Parekh BR, Tiwari Mishra SA, Kapse AR, Dhawale KM. Implementing integrated curriculum in advanced teaching in the fundamentals of homoeopathy utilising flipped classroom, case-based learning and group discussion: Post-graduate homoeopathic education. J Intgr Stand Homoeopathy 2023;6:102-7. doi: 10.25259/JISH_7_2023
Abstract
Objectives:
Successful homoeopathic practice demands the integration of various knowledge of homoeopathic philosophy as well as psychology to clinical medicine, repertory, and materia medica into a meaningful whole. Case-based learning (CBL), flipped classroom (FC), and group discussion (GD) methods have been found useful in delivering the process of integration in the classroom.
Materials and Methods:
A team of teachers (one from each six PG departments) and a coordinator conducted the sessions. The following steps were delineated: Identifying a suitable case, preparing assignments for individual FC sessions, individual feedback, and GD. The teaching was conducted over eight sessions of 90 minutes each. Learning from each session was consolidated in the form of PowerPoint presentations at the end of the session. Students were asked to write their experience of learning from each session, which the teaching team conducted.
Results:
Combining the methods of CBL, FC, and GD in the backdrop of adult learning principles helped to deliver a well-rounded experience of practice in the classroom. This improved classroom engagement and developed critical thinking and problem-solving abilities in students. The method also helped to deliver deeper learning as students were actively involved throughout the process of learning.
Conclusion:
Implementing an integrated curriculum is challenging. A team of dedicated teachers with the common aim of delivering excellence in education willing to undertake the arduous journey with the students is essential. Minute planning and execution requires clarity of various clinical and homoeopathic concepts and their application. Combined methods comprising CBL, FC, and GD were found to be useful in implementing the challenging task to deliver certain vital concepts of the integrated curriculum.
Keywords
Adult learning
Critical thinking
Integrated education
Problem-solving
Case-based learning
INTRODUCTION
Learning by doing and establishing the relevance of learning are the two key principles of adult learning.[1] It is important to incorporate these in post-graduate education to ensure better student engagement and improve the effectiveness of learning. Parekh et al. demonstrated the method of conceptualising and planning an integrated curriculum[2] in the classroom through the medium of case-based learning (CBL).[3] This paper aims to deliver the actual nitty-gritty of implementing such a curriculum in the classroom.
Flipped classroom (FC) is a paedagogical teaching method that aims at increasing student engagement using principles of adult learning. It is a blended learning method wherein students are given preparatory work in the form of assignments, reference readings, and pre-recorded lectures at home, whereas the classroom time is used to have deeper discussions on the topic under the guidance of a teacher where the focus is to identify and resolve misconceptions and foster problem-solving skills. Thus, in FC, what is done in class and what is done as homework are interchanged. Young et al. demonstrated that medical residents prefer FC over traditional lecture formats.[4] Various studies in medical education demonstrate the effectiveness of FC over traditional didactic methods. A randomised study conducted on 98 second year undergraduate students in pharmacology demonstrated the statistically significant effectiveness of FC over conventional small-group teaching in terms of improved students’ performance and learning experience.[5] A meta-analysis of 28 eligible comparative studies (between-subject design) showed an overall significant effect in favour of FC over traditional classrooms for health professions education (standardised mean difference = 0.33, 95% confidence interval = 0.21–0.46, P < 0.001), with no evidence of publication bias. More respondents reported they preferred FC to traditional classrooms.[6] A study conducted at the Queen Mary University of London, through thematic analysis of students’ responses, showed positive feedback from students, and they felt more active and engaged in the learning process.[7] In the current study, the FC model was used to implement an integrated curriculum in the classroom.
The group discussion (GD) method involves the presence of learners with variable databases and emotive makeups solving a given task. Traditional education is mostly passive absorption of what is taught in the classroom. It is unidirectional towards the students. This does not create opportunities for free expression and exchange of ideas. Cooperative learning is almost non-existent. The GD situation involves active face-to-face interaction and provides immediate feedback, thus providing the opportunity for self-evaluation.[8] The classroom gives a platform for the students to share the ideas and concepts they have grasped through the assignment. This helps the exchange of views between different learners and helps students improve their communication, critical thinking, and problem-solving.[9] GD also sharpens the sensitivities of the students, which in turn develops their cognitive and affective abilities, fetching rich dividends in clinical practice. This learning situation brings different intellectual and emotional attitudes with regard to a viewing of a problem.[10]
A study conducted on 1st year MBBS students at the Pramukhswami Medical College, Karamsad, regarding the effectiveness of the GD method in teaching learning in the dissection hall found a significant increase in active participation of most students. The majority of them agreed that this method helped them better understand the subject, improving dissection skills and communication.[11]
MATERIALS AND METHODS
The different stages employed in the learning programme are described in detail.
Background
Homoeopathic practice demands the integration of various knowledge of clinical medicine and psychology with homoeopathic subjects of organon of medicine and homoeopathic philosophy, repertory, and materia medica. Thus, to deliver the process of integration between various subjects, a team of teachers (Assistant Professors), one from each subject, along with a coordinator (a senior faculty- preferably an Associate Professor or a Professor) who oversees the entire planning and implementation, was formed. The integrated sessions were conducted weekly, and each session lasted 90 min. A successfully treated case was selected. This entire team was present throughout the session series.
Planning
The process of planning started with the identification of a case of a dimension that would bring out various complexities of clinical practice and have a good remedy response. A case of pilonidal sinus, which responded well to Fluoric acid was selected for the sessions. The treating team formulated learning objectives as per the various dimensions of the case. These were discussed with the coordinator and were refined, keeping the various themes of the curriculum as reference points.[1]
Preparation
The case was now circulated to all the participating teachers for their opinions; they were also invited to solve the case. This process helped them to grasp its various dimensions. The actual events of the case were then circulated to the teachers, giving them standard and common reference points. It enabled them to reflect on their work, correct errors, and resolve doubts. The case was circulated, and the students were also given specific directives for each session of 90 min duration along with specific reference reading to address the directives. Thus, they were not overburdened with solving the whole case and could focus on specific learning objectives of individual sessions. The students were expected to work on the directives before the session and submit their work to their respective department teachers.
Evaluation
The teachers, who were now well aware of the case, gave individual feedback to the students on their submissions and were encouraged to re-work the errors. Thus, students came prepared to participate in the GD. A pre-session meeting to plan the conduct of each session was done, during which each teacher shared the strengths and the weaknesses of students’ workings to better implement learning objectives.
Sharing
During the session, the students shared their understanding of the case and exchanged views on its different dimensions. This enabled an understanding of different viewpoints, thus helping to expand the knowledge base and to get feedback, leading to the development of critical thinking. It also paved the way for initiating deeper learning and addressing key difficulties faced by students, one of the key features of FC.
Consolidation
Consolidated PowerPoint presentations of important concepts from the case were decided and prepared by students under the guidance of the teachers. This helped in delivering the take-home learning. The students wrote reports on standard headings after every session, which were e-mailed to the entire team and evaluated for the learning derived and difficulties faced, which were addressed in the next session.
Analysis
At the end of the session, students wrote reports which reflected their learning experience and points that struck them the most. A master evaluation of all the reports was presented at the beginning of the next session to consolidate the learning and also address the difficulties. This analysis also helped in the further planning of the subsequent sessions.
The following table demonstrates the planning and preparation parts of the process described above through the illustrative case [Table 1]. The objectives are then divided into small directives, which, when worked upon, would lead to achieving the desired objective.
| Data from the case | Key aspects | Learning objectives | Explanation |
|---|---|---|---|
| Mr.V. M. a 20-year-old college student doing his B.Com. 2nd year reported with complaints of pain+in the inter-gluteal region with mild yellowish-white sticky discharge++for a month. The pain aggravated after stools++, by sitting++, and by pressure++. Local examination: P/R: Posterior to anus, small single opening, yellowish-white discharge present, hairy area. Excerpt from the life space The patient had an unconventional lifestyle. He was least interested in studies and was aggressive; was rude to teachers when contradicted. He cannot tolerate contradiction and gets abusive with physical fights. He started taking alcohol since 10th std and is involved in multiple relationships. He has had many physical relationships only to have sex. Whenever he used to watch any film/song he would get the desire and immediately call one of his female friends to have sex. The patient happily narrated that he has met with 4–5 drink-and-drive accidents with rash driving. Craving-alcohol+++, cold drinks+, chicken+++ and warm food+++, spicy+++. No aversions. Thermally: Hot patient |
The history and examination findings help to come to the diagnosis of pilonidal sinus. Through the life space, it is evident that the way of living of this patient is driven by base emotions which seek instant gratification. These are predominantly seen in the sexual sphere. The cravings also reflect the expression of his base desires. Obstruction to gratification leads to anger which turns out to be violent and abusive. Thus, it is important to understand this patient’s life and living through different philosophical and psychological perspectives |
1. Learning the process of clinical approach and disease classification to define the scope and limitations of homoeopathy in pathological cases and its reflection in the management of the case 2. Learning to receive a man operating at the level of ‘desires’ and finding suitable correspondence. Understanding the concept of normal/abnormal sexuality and morality/immorality 3. Learning the ‘concept of man’ from different standpoints (Hahnemann, Kent, Dhawale, Freud) to understand the personality of the patient and its reflection in miasmatic understanding at the mental level. 4. Learning how to take a suitable approach for the case and accordingly form repertorial/ non-repertorial totality 5. Materia medica differentiation at the level of the portrait of the patient and materia medica images |
Process of arriving at a clinical diagnosis and classifying according to the Hahnemannian classification of disease would help to clearly define the problem of the patient and give insight into the scope and limitation of homoeopathy in each case. The clinicopathological correlation will give insight into a miasmatic understanding of the case at the physical level. Exploring normal/abnormal sexuality, love/desire, monogamy/polygamy, premarital sex, dealing with taboos and inhibitions in the minds of young learners as it would be a challenge to receive and relate this patient and his way of living. Understanding the psychological processes from Sigmund Freud’s perspective (psycho-sexual theory) would give a better understanding of the patient’s conscious and unconscious processes leading to a comprehensive understanding of the patient. Insight to understand the patient better. Understand the patient as a person from various standpoints/concepts as reflected in the teaching of Drs. Hahnemann, Kent, Dhawale and Freud with its reflection in totality, reportorial/non-repertorial approach and remedial correspondence. Finding the suitable correspondence in materia medica through differentiation at the level of the portrait of patient and materia medica |
Implementation
The following directives based on objectives were formulated, which were to be worked upon by students before the session. These covered a span of eight sessions.
Go through the screening form, location, sensation, modality, concomitant columns (LSMC) and examination findings and come to a clinical diagnosis. Describe any difficulty in doing the same and how would you overcome it? What is the importance of diagnosis in homoeopathy? What do you think is the scope and limitation of homoeopathy in this condition? What is your miasmatic understanding?
Read life space and pen down ‘feeling state’. How would you relate with this individual during case-taking and/or follow-ups?
Pen down your understanding of the patient from the standpoint of Kent’s concept of mind
Read the concept of mind from Symposium Volume B by Dr. Dhawale and relate the understanding with that of the patient
Read Structure of Mind-ID, EGO, Super-Ego as given by Freud from the references given. Write your understanding about ID, EGO, Super-Ego. Identify how you can see its reflection in the patient’s life
Enlist all symptoms of a case and classify and select a suitable approach with reasons
Identify the dominant miasm at the level of mind and body with suitable reasons
Construct repertorial/non-repertorial totality and arrive at a group of remedies
Differentiate the close remedies and arrive at the similimum.
Specific objectives were defined for each session. Since the students came with prior work, the methods adopted for the session were free sharing, GD and resolving the students’ practical doubts. This process was facilitated by a team of teachers. The environment of the session was non-confronting and free. These interactive discussions were followed by presentations made by the students under the guidance of the teachers to consolidate the take-home learning [Table 2].
| S. No. | Topics for slide presentation | Responsible persons/department |
|---|---|---|
| 1. | Clinical approach and disease classification. Defining the scope and limitations of homoeopathy in pathological cases and clinico-pathological-miasmatic understanding | Medicine department |
| 2. | Analysis of the life space – qualified expressions, attributes, defence mechanism and miasm Trying to identify various expressions – emotion, intellectual, behaviour, state, attribute, defence mechanism and miasm at the mental level | Treating team and coordinator |
| 3. | Concept of man as given by Dr. Kent, Dr. Freud, and Dr. M. L. Dhawale How man evolves – the world of desires, the concept of right and wrong, moral values – conscience Freud’s theory of psychodynamics Sexual sphere expressions of enumerated remedies –Fluoric acid, Lycopodium, and Nux vomica |
Psychiatry department |
| 4. | Rubric hunting – case-based symptoms Repertorial and non-repertorial approach – detailed Kent approach understanding with reasoning and non-repertorial method description | Repertory department |
| 5. | Materia medica differentiation – Fluoric acid, Lycopodium, and Nux vomica | Materia Medica department |
RESULTS
Some reports were studied, and excerpts from some of them (all of whom happened to be female) are reproduced below:
Student 1: Report was written within 2 days of the session on discussing the feeling state after reading the life story of the patient.
Through the discussion in the session, I understood various concepts of conservative versus modern culture, concept of sexuality, and nature versus nurture. These discussions made us think what we know about these concepts and also the gaps in our knowledge. The discussions on these concepts made us uncomfortable, but that only meant more learning through it. Personally, I have not found it comfortable to talk about sexuality. But through such cases and through discussion on it, we learn to look at the situation more rationally and not put forth our judgements. We should deal with our likes, dislikes and judgments about the patient. I am glad that I was able to get over my initial dislike for the patient and maintain a neutral stance.
Student 2: Report was written within 2 days of the session on discussing the feeling state after reading the life story of the patient.
Through the session, I learnt that it is very important to understand the exact expression of the patient and not interpret it superficially. After reading the life space we did not like that patient but through the discussion, I realised that is important to understand the patient and why is he like this? Learned the exact meaning of satyriasis and polyamory. Furthermore, I realise the importance of knowledge of sexuality so that we can talk freely with the patient.
Student 3: Report was written within 2 days of the session on discussing the materia medica correspondence of the case.
The session and the discussion helped me to understand different concepts like sexuality, likes, dislikes, and morality. The understanding of these is important to know the person and its reflection (in) the homoeopathic Materia Medica. I realise that to understand the patient in an unprejudiced way, a combination of analytic and synthetic approaches is necessary.
Student 4: Report written within 2 days of the session on discussing the life space analysis of the patient.
The discussion in the session was excellent. Initially, I was not able to derive the attribute of the patient from the given event, but after the session I could try to understand what went wrong.
Student 5: Report was written within 2 days of the session on discussing the materia medica correspondence of the case.
The experience of the session was good. The understanding of each remedy by different stalwarts is important because it helps to understand various aspects of remedy and its different facets.
Student 6: Report was written within 24 h of the session on discussing the feeling state after reading the life story of the patient.
I learnt what all things to be considered while receiving the patient and all precautions to take to keep stable during case taking.
Student 7: Report was written within 24 hours of the session on discussing the feeling state after reading the life story of the patient.
It was a great experience and discussion (on topic) which we never tend to discuss (reference to sexuality). The feeling state of all the students (with respect to the patient) was different, but through the session, I could understand that the physician should be able to keep the mind stable
Teacher 1 (female) Assistant Professor, Paediatric department, more experienced than others in the team with flair for writing detailed reports. Report written at the end of the entire series.
The whole series and individual sessions were well planned and executed with joint efforts of all students, teachers, coordinators and consultants which helped in achieving the objectives well. The step-wise case-based approach and incorporation of various concepts that came up during the course brought about the journey from known to unknown really well. The formulation of assignment reference reading given, and the planning of directives helped maximum learning of both student and teacher.
Teacher 2 (female) Assistant Professor, Medicine department, joined the department recently. Report written after the first session once the planning was done with the team.
The objectives formed were covering so many aspects that even I was wondering whether I knew all of them due to my discontinuity in practise and teaching. However, through the guidance of the consultant and coordinator, we could evolve the standard of the case. Students kept on improving as the case progressed with timely submission of assignments, some of which worked out exceptionally well and helped the team incorporate more complex concepts.
DISCUSSION
The case became an important medium of learning experience, especially regarding the concept of sexuality, which many were resistant to address. All the participants acknowledged that it was important to acquire various knowledge of the same. It also paved the way for understanding one’s concept vis-a-vis the academic concept of sexuality while receiving a patient with high sexual desire and multiple partners. This was acknowledged as an important step to evolve as an unprejudiced observer by knowing oneself. The feelings of the patient generated in the group and its handling through GD helped the students to stabilise themselves, thus demonstrating the importance of critical self-evaluation paving the way for deeper learning experiences and change. The GD also helped the students to critically reflect regarding the exact qualities of the patient without concluding superficially; this was important as it would reflect in the selection of the remedy and overall management of the case. It is important to read from different textbooks of materia medica to understand different facets of the remedy which would help change the fixed thinking pattern of remedies.
The teachers, through the process, learnt the importance of proper planning and teamwork. The minute planning of the sessions with appropriately formed assignments and reference readings helped the travel from known to unknown and achieve the objectives through teamwork. The students could solve the assignments which helped in incorporating more complex concepts in the planning of the session.
Thus, we see that a judicious combination of the learning methods CBL, FC, and GD in the backdrop of adult learning principles helped deliver an all-round experience of practice into the classroom, improved engagement, and developed critical thinking abilities in students. The method also helped to deliver deeper learning through reflection and change as students were actively involved throughout the process of doing assignments and receiving feedback. It helped the teachers as well. A further paper will outline in detail the process of learning and the effectiveness of integrated learning through a qualitative analysis of the serial reports of all the sessions.
CONCLUSION
Implementing an integrated curriculum is challenging. A team of dedicated teachers with the common aim of delivering excellence in education willing to undertake the arduous journey with the students is essential. Minute planning and execution require clarity of various clinical and homoeopathic concepts and their application. CBL, FC and individual feedback, followed by the GD method have been found to be useful in implementing this challenging task.
Ethical approval
The research/study is approved by the Institutional Ethics Committee at Smt. Malini Kishore Sanghvi Homoeopathic medical college and hospital, a unit of Dr. M. L. Dhawale Memorial Homoeopathic Institute, Palghar, Approval reference number MKSHMC and H/1685/2022, dated 13th June 2022. The Research is registered in CTRI (Reg. No. - CTRI/2023/02/049864).
Declaration of patient consent
Patient consent not required as there are no patients in this study.
Conflicts of interest
Kumar M. Dhawale is a member of the editorial board of the journal.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship
Nil.
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