A total of four single interviews, one dyad and five focus group discussions were held with participants. There were a total of 35 participants with 23 being school entrants and 12 graduate entrants. Three focus groups were equally balanced with the same number of school entrants as graduates and one focus group was comprised only of school leavers. (See Table
for the demographic characteristics of the interview groups). Six themes were identified. These were: two separate programmes; problem-based learning and ‘Garmins’®; see patients for real, being seen as doctors; assessment: of mice and MCQ’s; a cry for support; personal growth and pride.
Demographic Characteristics of Participants and Type of Interview
Two separate programmes
Participants made several comments about the structure of the curriculum and the integration of learning. While there were a number of positive comments about the structure of the curriculum, often the comments suggested that participants did not see the relevance of information until later. One student reflected:
"“I would go back to my files and I’d think, … we actually did this.”"
In contrast some participants felt that:
"“our theory was great, we were complete clinical idiots.We had a lot of knowledge but we had no idea how to apply that knowledge … (in the clinical situation).”"
Commenting on the relationship between GEMP 1 and 2 and preparation for GEMP 3 and 4, a participant noted that “it links up perfectly.” In GEMP I and 2 students are taught to master a systematic approach to examining patients before contact with real patients. This is a practical skill that is taught in the clinical skills unit. This opinion was not held by all the participants. One participant described the programme as follows:
"“(the) GEMP is almost sort of two separate programmes …..where 3rdand 4thyears (ie GEMP 1 and 2) are very different from 5thand 6thyears (GEMP 3 and 4).”"
Participants felt that a great deal of information is covered in GEMP 1 and 2 but the relevance of the information is not apparent unless it is “actually applied to real patients.” The lack of application was particularly felt in relation to the learning of pharmacology. One participant described the benefit of learning pharmacology in the clinical situation, saying:
"“where you (get to see) where you can use a certain medication … instead of … rote learning.”"
The value of the clinical years was frequently referred to with one participant reflecting that the four years should be merged. S/he described it as follows,
"“so we like study it and then do the prac, study it and then do the prac.”"
There was unanimous agreement that participants felt a need for changes in the teaching of pharmacology and microbiology. Likewise, there was consensus across all the participant groups that the clinical experiences obtained at the different hospitals varied greatly. When participants had had the opportunity to be allocated to different hospitals at different stages in the programme it was described “as the perfect combination.” For some participants the difference in learning opportunities and standards was problematic.
"“I think the biggest flaw with GEMP 3 and 4 is that there’s sometimes a very big discrepancy between different hospitals. I’ve never managed an MI (myocardial infarct,) I’ve never managed unstable angina. That to me is a problem.”"
Problem-based learning and ‘Garmins’ ®
Participants could see the value in problem-based learning (PBL) but felt that it was not contributing to their learning as it was intended.
"“Often the theory and the actual practice of what is meant to be happening doesn’t always come through as strongly as possibly it was meant to when it was theoretically put together.”"
There was agreement that the PBL 2 session is not meeting its objective. One participant said:
There was acknowledgement that the group process contributed to the PBL process, as one participant stated “we all know how groups can be …,” while another participant stated:
"“the way that PBLs are structured. It’s that you’re put in a group with all different types of people who you don’t know so you all get to interact and you get to learn life skills. And you go on to your clinical years put into different groups and you sort of develop that interaction with different kinds of people with different socioeconomic group.”"
A positive group experience resulted in one student saying,
"“I loved PBL … I really enjoyed PBL…I had some really good people in my group. I learnt more in PBL with those students than I did probably in lectures.”"
There was consensus that facilitators influence the outcomes of PBL, with clinicians seen as being more comfortable with the subject matter as compared with non-clinicians. At the same time clinicians were seen as being more capable of guiding students in their learning. One participant described a good facilitator as a Garmin® (a navigation device):
"“I would just look in a textbook… it was like I needed a Garmin® to find what I needed in a textbook... a physician or a doctor you know,… they understand where you need to go, they can kind of be your Garmin® … And you really, really need that .”"
See patients for real, being seen as doctors
Despite the variability of the clinical experience where the participants often have to take responsibility for their own learning, the participants placed great value in their clinical teaching as bringing them successfully to a point where
"“we’re walking out from almost working as interns to working as interns.”"
Reflecting on the value of the clinical learning experiences, another participant stated:
"“It is only in 5thand 6thyear (GEMP 3 and 4) that I felt I learnt the most. That is when I became competent. I don’t think I’m completely competent yet, but I feel confident at the moment. And I think that is because of the clinical exposure I’ve had.”"
There was a mixed response to the early clinical exposure with some participants appreciating the “systematic approach which gets drilled into us in GEMP 1 and 2” in the clinical skills unit. However, participants felt that this learning experience should be
"“taken more seriously and more emphasis placed on(it)....you have to be here and you have to do it – and it must also be taught properly.”"
This statement reflects the need for joint responsibility between teachers and learners in this process.
Participants commented on the dearth of good clinical teachers while expressing great praise for those teachers who excel.
"“I really don’t think all of the guys are great at teaching but some of them were fantastic. There are some guys who really are good at clinical teaching and bringing concepts alive, you know exactly what’s going on when you walk out. And those guys are great.”"
While participants appreciated the biopsychosocial approach to patient care, they reflected that in the earlier years it was a
"“lost opportunity because you only see the value of it (the biopsychosocial approach) in GEMP 3 and 4 and at that point it’s in the past and you don’t really care about it anymore.”"
This discussion was taken further when participants elaborated on the value of the clinical years:
"“(I) honestly think that’s where you are made into a doctor;… how you are approaching a patient and that initial approach is really the crux of what makes a doctor and we only learnt that in 3 and 4 (fifth and sixth years); so I would definitely extend that to the maximum point possible.”"
Assessment: of mice and MCQ’s
Participants raised many issues in relation to assessment. The subjectivity of assessors and a lack of standardization in the assessment process in GEMP 3 and 4 were recurring comments as exemplified by the participant who said:
"“it’s not about what you know … a lot of the time it’s about who examines you. … If you get a nice examiner … and if you get a nice patient… so if you get something straight forward like cholecystitis, you’ll pass that case.”"
A contrasting but less common opinion was that:
"“it’s (assessment) very well standardized because they have a marking sheet.”"
These reflections on differences were related to the differing pass rates in the different disciplines.
The difficulty of questions in relation to the purpose of the assessment was interrogated, as one participant explained:
"“the exam is not there to prove what you do know, but maybe to nail you for what you don’t. If you don’t know the management of lupus nephritis, what’s the tragedy as a GP (general practitioner)?”"
Frequent mention was made of being assessed on rare conditions such as
"“a polycystic kidney, … an asperger, … a Takayasus.”"
In this regard there was a common perception that
"“some people have better luck with those cases than others.”"
The multiple choice question format was singled out as being:
"“very random (with the result that if) the professors are gonna show me how clever they are, I’m just gonna throw darts at a multiple choice sheet.”"
Subjectivity of assessors was particularly evident in the allocation of ward marks. One participant stated that:
"“you either get the consultant who just doesn’t care and gives everyone a 90 or 100% … on the other extreme you get the consultant who uses the ward mark as their opportunity to nail students unfairly.”"
Experiences of subjectivity in relation to ethnicity were also raised, as forms of both negative and positive discrimination. One participant felt that:
"“everyone is aware of race, they either tend to be more liberal, but then on the(other) hand, there is a prejudice coming in. I know one of the guys in my rotation just gets nailed every single time for assessment, whereas he’s actually a very good student.”"
Another participant described how he had adopted coping strategies to counteract examiner bias by learning
"“very quickly that you go to the exam like a little mouse, avoid having a personality in the exam.”"
Inadequate feedback was a problem both for those who did well as well as for those who had failed a rotation. As one participant said:
"“there’s no value in me repeating a block without knowing why or how you are failed.”"
"“If you really want to grow you should know what is right and what is wrong.”"
Clear insights into some of the problem areas in assessment were however often accompanied by recognition of an alignment between the learning and assessment. One participant stated:
"“Overall generally our assessments are good because we’re covering good academic knowledge or theoretical knowledge with our MCQs and a little bit with our OSCEs. We’re covering good clinical skills assessments with the Clinicals or OSPEs, so I really do think it is actually well matched.”"
A cry for support
Participants described the impact which the clinical years had on them emotionally. In the words of one participant:
"“in medicine (at a large academic hospital) there are 60 beds in (a) ward andpeople are sick. People don’t get exposed to that at our age, you know. You grow up quickly and if you don’t, you just suffer.”
Another student stated that:
"“there are two different sufferings, there is the academic stressful situations and then the emotional things.”"
The academic “sufferings” related to seeing colleagues fail and having to repeat a block of study while the “emotional things” related to “seeing your patients pass away.” In one of the focus group discussions participants described the impact that a counselling course had had on them personally.
"“We got to sit in a group and the amount of people who opened up and said that things were bothering them and one said that you begin to think that is normal. It made a huge difference … when you start doing the psychosocial side of things, you can’t just teach us a lecture (sic), then throw us out there.”"
Personal growth and pride
Participants reflected on their personal growth with a sense of pride.
"“The person I am now compared to who I was at the beginning of the fifth year are miles of difference. It was ridiculous, I was like a child, I wore long sleeves …so scared to come near anyone…now you just get in there, you know, you need that confidence.”"
The value of developing skills in life long learning and evidence-based medicine was recognised through statements such as:
"“the latest thing on treating congestive heart failure is this, and we have got to start getting into the idea of not all studies are great.”"
Patient centredness was described as something that has to be learnt practically and as one of the concepts that distinguishes the programme from those at other universities. One participant explained it as follows:
"“I think PD (patient-doctor theme) - it’s very underestimated in the course, it’s very important…that’s what differentiates us from other doctors.”"
There was a clear recognition that having had a lecture about ethics or patient-centeredness does not ensure that the student will behave or act in such a manner. One participant explained:
"“we are taught ethics and morals but I think there’s sometimes that …no okay we taught the students about ethics, they are now ethical…but that does not happen…for some.”"
A need for a practical approach in the teaching of ethics particularly to prepare them for the world of work was expressed as follows:
"“speaking of ethics…I don’t feel like we actually get taught the kind of ethics that we need out there to protect ourselves legally…you should be read practical cases.”"
Participants reflected on a professional responsibility to their peers in the learning sites as they provided support and guidance:
"“this year the fifth years came to us and we helped them....They asked, can you show us your patients…then they felt more confident.”"
Community engagement was acknowledged as one of the rewarding experiences of the GEMP programme:
"“going out into the community to educate the community and ja, give back as a medical student and help in the clinics.”"
Several of the interviews concluded with an emotional statement, such as:
"“It (the programme) pushed me to really do my best; as an aside I’d like to add that I think we’re all proud that we came to Wits. I know we complain, it’s the nature of beast, 200 students are not going to be happy. We are glad we came here…We’re ‘Proud Witsies’.”"