Experiences of clinical practice in a problem-based learning medical curriculum and subsequent clinical environments.

Abstract

The study traced the experiences of learning the clinical aspects of a problem-based learning

(PBL) medical curriculum and the participants’ construction of a relationship with the

subsequent clinical environments. In light of international and local medical and technological

changes, the Nelson R Mandela School of Medicine (NRMSM) changed its traditional

curriculum to a PBL curriculum in 2001. The participants were the first cohort to experience a

PBL pedagogy and graduated in 2005, subsequently undertaking two years of compulsory

internship and one year of community service within the South African health care system. It

was in the context of these changes and the present state of health care that such a study

sought to determine how a PBL pedagogy was experienced within the clinical environments

of South Africa.

Phenomenography was used as a methodology to describe and interpret the ‘qualitatively

different ways’ in which the participants’ experienced the phenomenon. Purposive sampling

reflecting the institution’s admission policy regarding race and gender demographics was

applied. In-depth interviews were conducted at the end of the community service experience.

Variation in the experiences was represented through logically related and hierarchical

categories of description resulting in the formulation of an outcome space.

The outcome space identified three categories of description: ‘The guinea pig identity’ which

found that the participants felt at the mercy of a curriculum experiment and felt discriminated

against by the hospital consultants who had negative views of PBL. The category of

‘knowledge construction’ saw the participants exploring issues of difference between the

knowledge and practices expected by the two different kinds of curricula. The category of

‘professional identity’ indicated an emerging sense of competence across a range of clinical

situations.

Critical discourse analysis (CDA) was used to augment the phenomenographic analysis and to

explore the ways in which the social structure of the clinical contexts related to the discourse

patterns emerging in the phenomenographic categories in the form of power relations and

ideological effects. CDA was used as an additional lens to develop theory and acquire deeper

knowledge about why the participants constructed a relationship with the phenomenon and

the subsequent clinical environments in the way that they did.

The thesis concludes with a proposal for an empirical model that illuminates resolutions from

the major findings in the study regarding medical knowledge construction in a PBL

curriculum. The model consists of a Y axis depicting the vertical spine of basic sciences

knowledge construction, a X axis depicting the horizontal nature of professional identity

construction and a spiral that indicates the simultaneous movement of clinical knowledge

construction along each axis. It is hoped that this model will serve as a future curriculum

innovation that will result in the production of professional medical practitioners that are

required for today’s South African communities. This study, however, revealed that despite

the hegemonic practices and the theoretical inadequacies that were reported by the

participants they finally felt like professional medical practitioners during their community

service experience.