Saras Reddy Doctor of Philosophy in Education UKZN, December 2010 EXPERIENCES OF CLINICAL PRACTICE IN A PROBLEM-BASED LEARNING MEDICAL CURRICULUM AND THE SUBSEQUENT CLINICAL ENVIRONMENTS Saras Reddy Doctor of Philosophy in Education UKZN, December 2010

FOCUS OF STUDY Study focused on the clinical expertise in a medical curriculum and therefore traced the experiences of learning the clinical aspects of a PBL curriculum (the phenomenon) and the participants’ construction of a relationship with the subsequent clinical environments.

CRITICAL RESEARCH QUESTIONS What were the participants’ experiences of learning the clinical aspects of the PBL medical curriculum? How was the relationship between the experiences of learning the clinical aspects of a PBL medical curriculum and the experiences of the subsequent clinical environments constructed? Why did the participants construct a relationship with learning the clinical aspects of the PBL medical curriculum and the subsequent clinical environments in the way that they did?

Hospital Clinical Practice LOCATION OF THE STUDY Diagram of the different clinical environments and the levels of experience. Rural Hospital Comm Service Urban Internship Hospital Clinical Practice (Urban hospital) Simulated Clinical Practice (Skills Lab) Student Year 3 - Year 5 Student Year 1 - Year 3 The diagram represents the different clinical environments and the levels of clinical practice through which the participants’ experiences were traced.

RESEARCH METHODOLOGY Phenomenography – qualitative research methodology was used in the sampling, data collection and analysis to describe and interpret the qualitatively different ways in which the participants ‘experienced’, ‘conceptualised’, ‘perceived’ and ‘understood’ the phenomenon. Critical Discourse Analysis (CDA) was used to augment the phenomenographic findings in order to explore the ways in which the social structure of the clinical contexts related to the discourse patterns emerging in the categories of description in the form of power relations and ideological effects.

RESEARCH PARADIGM Most medical research including medical education research is predominantly located within a positivist paradigm. The study was initially located within an interpretive paradigm that was intended to describe and understand the participants’ experiences of the phenomenon. After uncovering the phenomenographic findings, there was an epistemological shift into the critical framing that aimed at exposing and illuminating the social discursive practices in the clinical realm.

PRODUCING THE DATA A purposive sample of 15 participants was selected ensuring representativeness and variation in experiences. Target group: the first cohort of students who registered for the PBL MBChB Programme in 2001. Adhered to the University’s Admissions policy: 10 Black, 3 Indian, 1 White, 1 Coloured. Geographic location of participants: rural hospitals in KZN. Ethical considerations were adhered to. In-depth interviews were conducted at the end of Community Service Experience (+/-2 hours in duration) Interviews were transcribed verbatim Transcripts were member-checked to ensure credibility and reliability of the study.

PHENOMENOGRAPHIC ANALYSIS The main aim of the analysis focused on the meaning found within the transcripts. The meanings were used to construct categories of description that captured the qualitative differences between the ways of experiencing and the relationship that was constructed between the participants and the phenomenon. The what-aspect (structural) and the how-aspect (referential).

THE PHENOMENOGRAPHIC OUTCOME SPACE WHAT-ASPECT (STRUCTURAL) CATEGORY WAYS OF EXPERIENCING GUINEA PIG IDENTITY Conceptions of being in the experimental first cohort. Conceptions of labelling by medical ward staff. Conceptions of being compared with traditional curriculum students. Conceptions of racism and marginalization. KNOWLEDGE CONSTRUCTION Conceptions of learning in a Skills Lab. Conceptions of transference of skills from a simulated to a real clinical context. Conceptions of clinical competence. Conceptions of clinical assessments. Conceptions of theoretical inadequacy. Guinea Pig Identity Category was loaded with hegemonic behaviour, discrimination and marginalisation that were voiced by the participants who claimed that they were victims of an experiment that the consultants in the hospitals had negative views about. The Knowledge Construction Category explored issues of how the participants perceived the difference between the knowledge and practices that were expected by the 2 different curricula, traditional vs PBL The Professional Identity Category indicated an emerging sense of clinical competence as medical practitioners across a range of work place situations. The participants experiences as students in a simulated clinical environment, the clinical education modules in the wards, the internship experience and finally the community service experience showed a progression from the narrowest extrinsic technical level to the broadest most inclusive level of intrinsic meaning. CDA was subsequently used to analyse why the participants constructed a relationship with the clinical environments in the way that they did. HOW-ASPECT (REFERENTIAL) PROFESSIONAL IDENTITY Conceptions of transition from student to graduate. Conceptions of competence as interns. Conceptions of relationships with the health care team during internship. Conceptions of relationship with rural practice.

CDA Gramsci’s Hegemony Theory was used to interrogate and problematise how the discourse of the ‘Guinea Pig Identity’ impacted on the participants’ experiences. Bernsteins’ Theory of Knowledge Structures was used to explore and illuminate how the different expectations of a traditional versus PBL construction of medical knowledge had power and effect on the experiences. Professional Identity Theory was called upon to show how an emerging sense of clinical competence across the clinical contexts was achieved regardless of the power relations and ideological effects of the discursive social practices experienced. From the participants’ perspectives and my theorizing around the findings of the study, I proposed an empirical model that situates and understands the participants’ interactions between learning in the specific discipline of medicine and their ability to clinically engage in it to become professional medical practitioners.

MODEL OF MEDICAL KNOWLEDGE CONSTRUCTION The model represents the vertical nature of basic sciences knowledge, the horizontal nature of professional knowledge and the spiral manner in which clinical knowledge is constructed in a medical curriculum.

BASIC SCIENCES KNOWLEDGE CONSTRUCTION The basic sciences knowledge in Curriculum 2001 was integrated into the paper cases of the Themes (Yr1-Yr3). Participants reported theoretical inadequacy in basic sciences. Would medical practitioners be able to arrive at a differential diagnosis without having the basic foundational knowledge behind their clinical reasoning process?

BASIC SCIENCES KNOWLEDGE CONSTRUCTION CONT… Vertical knowledge structures eg. Anatomy, Physiology and Pathology cannot be floated into the spiral of a PBL. Quality assurance measures required to ensure all core objectives are integrated into the paper cases. Careful oversight is needed to ensure that the objectives are elicited during the facilitated sessions. Proposal is to vertically increase the progression of basic sciences in a sequential approach to ensure no gaps in knowledge construction – needed to arrive at a diagnosis of a patient.

PROFESSIONAL IDENTITY CONSTRUCTION Professional development such as communication skills, ethics, teamwork, etc can be paralleled to Bernstein’s horizontal knowledge structures, each skill has no particular order but should be integrated horizontally across the 6 year programme. This would ensure an ontological and epistemological awareness of the discipline resulting in the adoption of a philosophical and moral stance that would be aligned to their own sense of being.

CLINICAL KNOWLEDGE CONSTRUCTION The model suggests that clinical knowledge can be developed in a spiral manner that aligns itself to the vertical development of the basic sciences and the development of a professional identity. Clinical education should begin in the first year in a simulated environment and gradually broaden out into the clinical years constantly ensuring the reinforcement of all the communication, physical examination and procedural skills until a sense of competence and confidence is achieved.

CONCLUSION NRMSM experienced a rapid change – traditional to a PBL curriculum – a complete paradigm shift. In its haste did they put in sufficient oversight - decline in the clinical skills ability and clinical acumen of its graduates? Study was able to determine whether the participants were ready for their professional identities. Study concluded that despite the theoretical inadequacies and hegemonic practices experienced, an emerging sense of professional identity was constructed. A progression from the ‘guinea pig’ identity to the ‘professional medical practitioner’ identity was finally achieved during community service.