MBBCh 5 and 6

In MBBCh 5 and 6 the undergraduate programme is structured in discipline-based clinical rotations. In MBBCh 5 students write an integrated year-end examination and in MBBCh 6, a final integrated year-end examination assesses all learning from the last five years of the programme. In these last two years of the undergraduate programme students spend most of the time in the clinical area where there are several opportunities to integrate all the learning in clinical blocks and rotations.

Student 6 shares positive experiences about integration in these years of study:

That foundation gets laid in your fifth and sixth year...as you go higher and higher in the years you pull in more resources, compacting them into your categories or boxes… [Student 6, MBBCh 6]

In terms of fifth year and sixth year they add more combined rotations like the IPC for example … brings in everything from Surgery, Medicine, Paediatrics.

That’s a nice integrated block where you are learning Family Medicine, where you learning your GP work. Basically when you’re sitting in and any patient can walk in, that’s what’s nice about that block. You know you can’t say I am only seeing Cardiology patients, you Neurology step aside because in that block you see what patient comes in front of you, be it a kid or be it a pregnant person or....in that block it’s nice… [Student 6, MBBCh 6]

The perception of students on their preparedness for vertical integration is that it is not adequate. This is their preparation for integration from problem-based learning into the clinical areas in MBBCh 5:

… even though we had problem-based learning which I think was an introduction to integration, I don’t think I could integrate at all in third year and fourth year…

it’s only now that I’m faced with things, I just feel like I have a better understanding and I can do it much better even though it’s not great but there is something going

on…I still don’t feel I was fully prepared for integration practically. So Uhm my real taste of integration probably only happened in fifth year… [Student 9, MBBCh 5]

The perception of Teacher 1 seems to confirm Student 9’s experience that the problem-based learning might not prepare students adequately for integration of learning:

… I do believe that…some students have really battled to understand what it is we wanted them to do when we put them into a problem-based learning group and tell them to discuss this case. They don’t necessarily have a sense of what it is that we’re trying to achieve and you can tell them what we want them to do, they can go through the emotions but that richness…of seeing how things are put together, I am not sure that everybody gets it equally… [Teacher 1]

This problem of compartmentalisation is acknowledged by the teachers whose perceptions illuminate lack of integration in the clinical area and in assessments:

…the teaching takes place mainly in academic tertiary centres and so that is always going to infer in a way that patients with specific problems are in specific wards and the people within those wards think in a particular way for the seven weeks or whatever the students are seeing a certain view of the world according to what that unit does and how it practises its medicine... [Teacher 8]

When it comes to GEMP 3 and 4, I think we need to turn it upside down… I think there is not a lot of integration, we still have compartmentalised this block, that block and then we have a major exam where we call integrated…is it really integrated? ...you know I don’t think so… [Teacher 6]

In the earlier years of study integration is perceived as a waste of time or too much work because there is no expectation to integrate and students still pass without integrating. However, in the final years of study the perception of the importance of integration rises as in the quotes below:

…if you can get by, through third year and fourth year, without integrating that you know that is a good indication of how the assessments need to change a little bit, because if you can just swot and get through your thing, you are not really thinking a lot you know so if you were faced with Uhm in the exams, more cases that forced us to integrate…it would help along the integration process…

[Student 11, MBBCh 5]

… you can get by third and fourth year without integrating… you really can. “Ja”

[yes], but you can’t get by fifth year because it’s such a practical year and the

patient as a whole is in front of you. You are forced; you're thrown in the deep end to integrate… [Student 10, MBBCh 5]

Student 10 experienced that the programme structure in MBBCh 5 forces them to integrate learning. However, Teacher 6 is of a contrasting perception that the integration in the programme is fragmented. The teacher explained that through problem-based learning there is a deliberate attempt in MBBCh 3 and 4 to encourage integrated learning theoretically, and to look broadly across different disciplines. But then:

...we put them in MBBCh 5 all of that is lost because now we go and compartmentalise everything so I don’t see much integration happening… in the three-week block we say there is integration, we send them for a day or two into physiotherapy or speech engineering therapist. That’s taking a chunk and putting a chunk in it… that’s not really integration… [Teacher 6]

In line with Teacher 6, the student below laments the ambivalence between the teaching and assessments in terms of integration. While the teaching is integrated in the block system, the assessment is not:

I think that in GEMP 3… a lot of the problems we come across in integration…

Uhm… with assessments is that …Uhm… during the block we’re faced with whole cases so we clerk a patient,… take down the entire history … do an entire systems review and we are meant to link everything together and then we get to the test … so you have a Respiratory session, you have a Cardiology session, you have an Abdomen session and they just test those things … I think that’s a little bit unfair …because it’s on the spot testing of just Cardio instead of “What was the history?”, “What did they present with?”… the actual thinking …Uhm…

the actual integration process that they expect you to do throughout the block.

[Student 11, MBBCh 5]

The experience of Teacher 7 is that attempting to strengthen integration of learning in this undergraduate programme is an insurmountable task:

…so from my observation…, there seems to be less commitment and engagement throughout with integration horizontally and vertically. So horizontally would be in the problem-based learning blocks, truly integrating the different disciplines, I did not see that. … Uhm… and then the vertical integration, I don’t get to meet with the physicians, for example…I don’t even know who teaches in clinical medicine you know...it’s going to take commitment really at the highest level at the faculty to deal with that,… Uhm… good luck!... [Teacher 7]