CONCEPTION 4

An even more sophisticated conception is that integration of learning is seen as a systematic process. However, there were variations on whether it is a taught process or one which develops and happens spontaneously with experience and learning from peers and others more experienced. The variations in conceptions were apparent in the conversations with Students 9, 10 and 11 who were interviewed together:

Uhm… and I don’t think integration could actually be taught, you’d learn from experience and also from tips with people with more experience, that’s what I find with the consultants and people that we meet on a daily basis in the fifth year.

They just… they give you a further understanding on how to put everything together… [Student 9, MBBCh 5]

…for me it’s pretty much a systematic approach, so I have got my headings for example…risk factors…aetiology...signs and symptoms...following that structure helps me integrate… [Student 10, MBBCh 5]

I disagree with that. I think integration is a learnt process you can’t just…if you take someone from second year and shove them into fifth year, they would not know anything, they wouldn’t know how to integrate or approach a case…it’s just for everybody, the whole integration process happens differently, but I think that you need to be exposed to having to integrate before you can learn how to…

[Student 11, MBBCh 5]

Student 10 explained above that when she has her headings lined up, she thinks of the disease as a whole based on the theoretical knowledge that she has acquired including the risk factors of this disease. Following this systematic process reminds her of how the patient presents with this disease, and all of that is mostly based on what she has seen in the wards. The student is relating to her experience which would have made it difficult to integrate that way earlier in the years of study before clinical exposure.

Student 11 affirms that integration should be taught while conceding that it happens differently in different individuals. The student alludes to the importance of experience in being able to integrate learning because, in MBBCh 2, students have not acquired much experience. Student 9 above foregrounds the role of experience by acknowledging integration tips they get from senior, more experienced students and teachers. Apart from integration being taught, people with more experience are seen to play a role in enabling students to integrate learning. Not only teachers are seen to be more experienced, peers are also included in the category of those who can assist with integration of learning. This makes integration a collaborative activity.

In contrast, teachers are of the view that students need to be taught how to integrate learning so they can consciously put it together. As mentioned above teachers think integration is difficult so students need to be taken through the process. Integration of learning needs to be made explicit to them particularly for the benefit of the average student who struggles with seeing links:

I don’t think that they can do it by themselves. I actually think that integration is something that you lead students through... I don’t think that our average students are actually capable of doing that...l think that it’s something that needs to be made explicit to students… often when you try to look for evidence of integration, you are going to see them throwing up their hands and rolling their eyes…

[Teacher 5]

Some students experience integration of learning as a process which runs through the undergraduate programme but with increasing complexity. The student below sees the subjects as contributing to a system:

That’s how life works, however, if I am studying first year Surgery, if I am studying first year Physics, the system is a system. There are inputs and there are outputs and there is a system as a whole and the variables which then interplay to it bring

about, they become more complex...but the fundamentals of how it is, they are still the same… [Student 4, MBBCh 4]

According to a final year student, integration is possible with pattern recognition following common patterns like signs and symptoms. Understanding common patterns will make it possible to isolate atypical presentations which require more thorough investigations. The students felt they needed to do this pattern recognition for the ability to manage patients systematically and comprehensively.

...when it comes down to the clinical aspect or what you Uhm doing in the front line it’s more when it comes to a pattern like recognition the basis of your integration…I remember seeing a patient like this, the patient had this, this, this, now you looking for things, you remembering how to do things and that’s how we talk much of integration and pattern recognition. That’s how you putting it and that’s your template now and then from there you start pulling out and asking...

[Student 6, MBBCh 6]

I think it’s literally exposure to cases that’s taught me to integrate because before that I thought very much in different blocks… [Student 11, MBBCh 5]

...because I feel that that’s, you know, the ultimate to be able to see patients and be able to understand what they are going through, Uhm... you know, the Biology of it and also emotionally and, trying to pull all the information that you have been learning and do what is best for the patient and what is best for the patient’s disease... [Student 5, MBBCh 4]

The student below expressed an experience of a consultant’s remarks in a clinical area. The student was failing to identify the basic information and integrate with the patient’s history in order to make a proper diagnosis:

You are just basically giving me back what I could have asked a patient. And at this stage I need you to be able to take the basics and what the patient has taught you and think about it in terms of a focused diagnosis... through time and through application of knowledge; they can do better... [Student 4, MBBCh 4]

... you go to hospitals as well and you start seeing patients and you start integrating your work with the patients and your theory because now you have to put theory with the practical and that’s where I like it... so like when you see a patient, you say: “Ok, I remember this, I remember the Anatomy, what's wrong with the patient, I remember a little bit of the Physiology, what's going on in the patient and I remember some of the Pharmacology I can treat the patient.” So I think it’s a learning process and I think that by the sixth year you should be able to integrate all the work that you have accumulated during the past five years and to be able to help that patient, that’s the way I see it… [Student 1, MBBCh 4]

Previous experience and application of learning in the clinical area are seen to be prerequisites in the development of ability to integrate learning. This is how a deep understanding develops, for integration to take place.

I try to think of whether I’ve learnt the stuff before or whether I’ve seen a similar thing before or I’ve heard about it somewhere or read about it before...from a personal experience. Yes, even when you studying you like “Oh, yes, this happened to me or this happened to my relative or whatever.”… [Student 3, MBBCh 4]

....so I think it’s nice when you have a lecture and....apply that to a real case, you know, to see a real patient. So you will be speaking about any disease like ulcerative colitis and you actually go to the ward and you see a patient with the signs and symptoms of ulcerative colitis...So I think that’s the best way to incorporate everything... [Student 2, MBBCh 4]

In agreement with the above sentiments, a teacher shared experiences on how students could be assisted with integration in the clinical area:

...maybe it would be more relevant to re-discuss the Physiology of the GIT¹ when they were seeing patients with peptic ulcers or diarrhoea as opposed to just hoping that they remembered what they learnt about the Physiology in second year… [Teacher 8]

…on the ward rounds I like to do things around the bedside and about specific patients what I like to do is apply whatever knowledge they have to those specific patients so it’s not just textbook recall and that sort of thing, it has to be mainly physiological and anatomical issues that fit in with what that case is demonstrating and that would be brought up at the time… [Teacher 8]

Student 2 refers to the critical nature of medicine, saving lives. For this reason, the perception is that it is paramount to set high standards for the management of patients:

... the pass mark, you know, the pass mark, the requirements to get in, all of those things, you know, can maybe be a higher step, because at the end of the day we are saving lives…we are dealing with patients and we are a very high professional career and you know, to have someone who actually knows 60 % of the work, like for example... he’s not good enough to become a doctor you know...

[Student 2, MBBCh 4]

1 Gastro-intestinal tract

Conception 4: Summary

In summary, Conception 4 is more cohesive and of a higher level of inclusivity.

Subjects are seen as a part of a system and the attitude is that integration of learning is not difficult. There are variations in experience of whether it is a taught process or one which can be learnt from peers and teachers who have accumulated experience. The system of integration becomes more complex and is likened to how life works. The ability to manage patients systematically and comprehensively is an inclusive conception which is superior to the other conceptions before this one. In managing patients, students apply their knowledge and skills in an integrated manner to solve patients’ problems. This perception of the act of learning for this ability is sophisticated, requiring pattern recognition, a deep understanding of the concepts and application in the clinical area.