In this section, we will describe the students’ experiences about the medical curriculum. We identified four themes and nine subthemes as described in Table 2.
Table 2 about here
Compartmentalized Curriculum in the Basic Courses is like the Missing Parts in a Puzzle
The experience of students in the first years of studying in medical school is simply attending classes to take basic courses such as biochemistry, physiology, anatomy and so on. From the students' point of view, these courses seem unnecessary because they have no specific connection with the clinic. As an example, student B stated:
“The basic science program was such that many of its courses, such as biochemistry and medical physics, were not very important and could have been presented more succinctly, and in my opinion, nothing would have happened if these courses had not been offered. The courses are taught by many professors mainly in the form of theory.”
Student F similarly stated:
“Basic science courses, anyone we ask says, are not important courses; they are useless because they have a series of lessons that have very little to do with the clinic in terms of content, and those parts that are related to the clinic, students do not understand the connection.”
Students believe that the large volume of content in the basic courses and holding theoretical classes in crowded classrooms yielded an undesirable from of education and this, in turn, has reduced their motivation. Student E stated:
“In the basic science course, we were not at a desirable level in terms of class population. For example, physiology class, which was also an important subject, was held with 120 students in the amphitheater. Who really wanted to listen to the class or take notes or whatever? Classes were like this, and so was the lab. For example, we had the anatomy classes like the anatomy of the body or the head and neck, in practice, but the classes were so crowded, and on the other hand, the number of corpses were so limited that it was not possible to work much on the corpses or to know precisely what was going on. The other classes were also the same.”
Student H mentioned:
“In total, the basic science course was not useful. Apart from this aspect of theoretical knowledge, it did not motivate or encourage questioning in any way, and it was mostly because the volume of the lessons was large and the things we had to read were too much. The volume of lessons was so overwhelming that we preferred to read only the pamphlets and books we had and we no longer had time for further why and how questions.”
What can be concluded from the students' experiences is that the compartmentalization of the curriculum has led to the implementation of basic courses with a purely theoretical approach, with no connection to clinical practice. Accordingly, these courses are offered in crowded classrooms with passive teaching methods.
Physiopathology Curriculum is Like Swimming on Land
Although students believe that recognizing diseases is the basis of medical science, they believe that the current way of instruction is like swimming on land. They mentioned gaps between physiopathology and externship courses and concentrating on exams and assessment rather than learning as the main reasons for the current situation.
The participants identified a need for selecting appropriate interventions for closing the gaps between physiopathology and externship lessons. They explained that their courses in physiopathology courses are not helpful for their externship period. Student K explained:
“I think physiopathology and externship lessons are not aligned with the needs of students. It would be better that physiopathology lessons to be adjusted with externship. It should be mentioned that clinical subjects are also theory-based.”
Student G also described her attitude as:
“The physiopathology course is an intensive and difficult course in which a lot of things are told to students in a short time, so the most fundamental thing that students do is to memorize their booklets, and take the exam, and pass. Professors do not guide us how to link our knowledge to clinical skills to have effective outcomes to use in our workplace.”
The participants explained that the learning environment is designed in a way that professors focus on exams and assessments more than learning. Student C stated:
“Memorizing chapters more than concentrating on learning confuses the students. Students spend their time and energy for just taking their exams and remembering the heavy content to pass the courses.”
The participants also described that concentrating on theory-based classes is a chance for the students to cheat the exam questions from senior students. They also described those theory-based classes as the cause of decreasing students’ motivation. Student N made this point:
“Experiencing theoretical courses for 5 years decreases students’ motivation. Students do not understand the reasons for memorizing the great amount of details and it is the main cause of decreasing students’ motivation.”
The findings of this section show that despite the importance of physiopathology courses in the diagnosis and treatment of diseases as the main medical function, the isolation from the action arena makes this part of the curriculum ineffective.
Externships as Touring to Mysterious Land
After four years in the classroom taking basic and physiopathology classes, going to the hospital and wearing a white medical uniform is very exciting for students. They attend in different wards of the hospital, waiting for opportunities to turn them into doctors, but what they experience is like a trip to Wonderland. They expect the knowledge they have gained over the years will act as a bridge helping them to transfer from university to the real therapeutic (medical) environment; however, they feel that the bridge is broken. For example, student G stated:
“We expected all the different courses we took in college to prepare us for real-life issues in the workplace, but our experience does not show that at all.”
They believe that the learning environment is very specialized and far from the expectations of a general practitioner, and this has led to inappropriate authenticity of learning assignments. For example, student J stated:
“We go to one of the most specialized hospitals in the city to do an internship. Patients who are referred to this hospital have advanced and specific diseases while I am supposed to be a general practitioner and treat common diseases that do not exist in such hospitals.”
Student A stated:
“There are various learning opportunities in the hospital, such as Morning Report, Professor Case, Clinical Round, but since all of these situations are the subject of an advanced and specialized disease, they are not applicable to our future work. On the other hand, in all these situations, in addition to general medicine students, there are also residents and fellowships, and these situations are more relevant to them than to us and the supervisor pays more attention to them.”
Students believe that there is a deep gap between what is learned in the classroom and practice in clinical settings. In addition, attending various wards of a specialized hospital prevents them from learning the duties of a general practitioner, and what is offered is more appropriate for a resident than for a future general practitioner.
Internships and Unleashed Arrows
Re-attendance of students in different treatment departments in specialized hospitals as interns is an opportunity to learn and perform therapeutic interventions. However, students believe that attending specialized departments has caused them to see diseases only from the specialized perspective of that department, and this has led to the formation of a myopic view in them. For example, student C stated:
“In every ward we work, they only analyze the disease from their point of view. For example, if the patient refers to the ear, nose and throat ward with symptoms such as headache and nausea, the disease is examined only from the perspective of the same organs of the body, and if he refers to the internal ward, the symptoms are analyzed only from the gastrointestinal dimension while I, as a future general practitioner, should have a holistic view of the disease.”
Students also state that due to the large number of patients in the ward and improper management of time and tasks, proper planning is not done for their internship and learning in such an environment depends on their luck and effort. According to this, student D stated that:
“We spend many hours in the hospital every day, but there is no specific schedule for us. If I show enthusiasm and I am lucky and the resident who is my supervisor gives me a chance to perform the treatment procedures, then, I will have a good learning opportunity. Otherwise, time often passes in vain. ”
In this regard, student I stated:
“There are good topics for learning in the curriculum, but due to the large number of patients, professors and residents are engaged in treatment, and learning depends on the extent that I am an active observer.”
Students are aware that core competencies such as clinical reasoning and problem solving should be developed by them and they have been emphasized in the curriculum. However, they believe that, in practice, there is no opportunity to learn such skills during their internship. Core competencies are not considered at all so that a unique opportunity for their development is missed. For example, student L stated:
“We know that we need skills such as reasoning, problem-solving, and decision-making to make right diagnoses, or that professional ethics are important, but in practice these issues are not considered by supervisors during the study, neither in teaching nor in assessment.”
Students expect to practice the duties of a general practitioner in a related work environment in their internship period. However, attending only specialized hospitals and lack of proper supervision by professors has turned the learning environment into a chaotic one where learning is more influenced by chance and luck than by being influenced by the program and the teacher. Moreover, in internships, specialization takes precedence over the development of core competencies such as clinical reasoning and problem solving.