MBBCh 3 and 4

In the third and fourth years of the undergraduate medical programme, students are taken through system-based blocks and rotations. Eleven systems-based blocks attempt to integrate content from four longitudinal themes in teaching and learning and assessment. Final integrated written and clinical examinations at the end of MBBCh 4 assess all learning from the two years.

In general, students experienced that it was the structure of the programme from MBBCh 3 onwards that aided their ability to integrate learning. MBBCh 3 and 4 are based on the problem-based learning framework.

The problem-based learning structure of the programme requires students to learn in an integrated manner. Some students experienced a direct relationship of problem-based learning with what they encounter in the clinical area, thereby enabling linking basic sciences with pathological sciences.

Because now you realise what they are trying to teach you in the ward rounds is exactly what your problem-based learning was about… [Student 6, MBBCh 6]

Problem-based learning is an introduction to that [integration] and you are learning from fellow students and consultants because those are our facilitators.

They are teaching us how the integration process works…in problem-based learning …hmm where they forced us to think about each aspect of the case in different slices and bring it all together… [Student 11, MBBCh 5]

Student 11 recognises the role fellow students play in the integration of learning.

…we were introduced to this concept of integrating everything together because of problem-based learning … [Student 9, MBBCh 5]

Uhm… I think the first time we were actually forced to integrate knowledge was when we were presented with case studies, so our problem-based learning, for example, Uhm that forced us to actually look at all aspects of the case… looking at the Physiology and Anatomy and being able to put it all together in that one case so I think only when you're faced with a problem… Uhm… or a case are you forced to integrate, but before that we’re learning very much in the blocks…

[Student 11, MBBCh 5]

In terms of the timing of problem-based learning, some students felt that it should start earlier in the programme. However, because of the block system which compartmentalises systems into blocks and specific clinical cases into weeks, the perception is that integration of learning is not promoted:

…I think that it [problem-based learning] is coming late into the programme because specifically with the blocks, that is how we should learn our theory and everything but in terms of problem-based learning where we’re supposed to integrate things together, if it’s Heart Failure week, you know the case is going to be Heart Failure to be honest before you have even heard the case and stuff…you sniff immediately from a mile away that he has heart failure…

[Student 9, MBBCh 5]

Teacher 8 seems to support the student’s experience that problem-based learning starts late in the programme. The teacher’s experience is that students are interested in early clinical exposure as it was conceived to be stimulating; and this is a motivator:

….I think there is a bit of a disconnect and students really are very interested in going to the wards early and doing practical things, touching patients, teaching patients… Uhm… you try to tell them that that will come but somehow they believe that their clinical exposure is important which stimulates them and I am sure it would stimulate them more… [Teacher 8]

Although problem-based learning was experienced as a good potential structure for integration of learning, it was not a direct component of any assessments; students did not take it seriously because they study in order to pass assessments as supported by the following quotations:

...you learn a lot in the problem-based learning or whatever…but they never actually ask you questions on it...your stack of lecture notes and then you study for your exam and instead of taking your problem-based learning cases...At the end of the day, that stack of lecture notes is what's going to get you to pass…

[Student 1, MBBCh 4]

I think that problem-based learning is very, very important, I just think that Uhm because we were too focused on trying to pass… Uhm… and swot a bunch of facts we… we sort of disregard it and then when the assessments come, they often test us on facts and the whole problem-based learning process is sort of like lost in the wind… [Student 11, MBBCh 5]

From the above sentiments, it is apparent that the potential role of problem-based learning to promote integrative thinking is really not used although it is perceived.

Teacher 1 below perceives gaps in the way in which problem-based learning is used. There is sometimes a perceived disconnection between problem-based learning and the lectures which are supposed to support the problem-based learning:

…there is the…problem-based learning case but there is the teaching event that happens outside of that and how those all link together…the students often see the cases as something separate from the lectures… so they’d [lecturers] just come and give an isolated lecture …without referring to the case of the week at all… and maybe they don’t even know that there is a case that week …their understanding of what this curriculum is meant to achieve… Uhm… I think is a crucial part of the success of the integration mechanism you know being effective… [Teacher 1]

In terms of progression from MBBCh 2 to 3, some students experienced difficulty with vertical integration because of the different approaches in learning in the different years. The volume of content in the third year was perceived to be similar to that of the second year; however, third year required the learning to be integrated:

And you have to have a different mindset going into second year and going into third year. Third year is more difficult in a sense that you're learning a similar

volume but you have to just put it all together in your mind…and I don’t think that we were fully prepared for that honestly… [Student 8, MBBCh 4]

The perception of Teacher 5 about problem-based learning varies from the students and other teachers. This teacher conceives of a different type of integration which may be of more value:

I have never been particularly keen about the whole problem-based learning idea, because....pause...I think that there is a value in the final transfer of information later on not to learn things in one particular context… [Teacher 5]