The research is situated in an interpretivist research paradigm and used an ethnographic approach. The data collected included in-depth interviews of students and participant observation conducted in the clinical teaching setting.
Data collection, analysis and reporting was carried out in line with the consolidated criteria for reporting qualitative studies (COREQ) 32 item checklist.(21)
Selection of participants
The participants were medical students in their 4th to 6th years of study and were approached face- to-face at the university residence and on campus and requested to participate in the study. Two participant who were approached declined to take part in the study, citing lack of time as the reason for not wanting to participate in the study. No participants dropped out of the study. Three students from each year were selected by means of purposive sampling, reflecting, demographically the medical school population. Even though racial classification is associated with the apartheid past, we continued to refer to it in this study as it is being applied locally.
Data collection and the positionality of the researchers
The first author (JS) collected the data during his internship. He graduated from the medical school where the study took place three months prior to conducting the interviews and the participant observations. Having been so intimately involved in the clinical setting, and having just recently graduated, he had deep knowledge of both the insider and outsider context of the study which was critical for a deeper understanding of many of the subtleties that emerged.
The second author (BG) is senior faculty at the medical school and did not have direct engagement with the participants in the study. He has been engaged in curricular work as well as educational research at the institution and thus had a deep understanding of the current curriculum, educational practice and context.
An iterative process of reflection involving the 2 researchers took place throughout the study, from its conceptualization, development of research proposal, data collection and data analysis. The potential influence of the participation, the insider-identity of the first research as well as a deeper reading of the history of the medical school was engaged with to increase a reflective exploration throughout the study.
Twelve semi-structured in-depth interviews lasting between 15 and 45 minutes were conducted. The interviews followed an interview schedule with five initial questions covering the objectives of the study and followed up additional reflections and explorations based on the responses from the participants. The interviews were conducted at student’s home or university residence rooms during the first semester of 2017. Only the interviewer and the participants were present during the interviews.
The interviews were audio-recorded and then transcribed to text verbatim. Non-verbal responses were documented in the researcher’s field journal during interviews.
A process of participant observation was conducted over a 6 month period at the teaching hospitals where 5th year medical students were placed. The observations were conducted by the first investigator mentioned above who documented interactions during ward rounds, tutorials and clinical teaching. Observations, which focused particularly on interaction between students and teachers, were documented in shorthand in the observer’s field journal as soon as possible after the event and then written into more detailed narratives within a day of the events taking place, to ensure as accurate recall as possible. .
Both the data from the interviews and the participant observations were initially analysed by the first investigator, and reviewed by the second investigator. The data from the 2 sources were treated separately and computer assisted data analysis software (NVivo®) aided in data analysis for the interview data. An open coding method was employed to group the data into themes, the codes and data were reviewed by the second investigator and were then progressively refocussed as broader themes emerged. These were then iteratively reflected on, compared and contrasted with the observation data. A deductive - inductive strategy was used for the coding. Major and minor themes are discussed in the findings below.
Measures to ensure trustworthiness were based on Guba’s criteria.(22) Credibility was ensured through persistent participant observation over six months in the clinical setting and through triangulation of the data sources between the interviews and the participant observation. Researcher triangulation was conducted, as the first investigator analysed the data, and the second rigorously reviewed the analysis process.
All data collected from field notes and transcription of interviews were cross- referenced and analysed by both researchers, increasing its dependability.
The study proposal was reviewed and approved by Bioethics Research Committee (BREC Number BE381/16) of the University of KwaZulu-Natal. Gatekeeper permission was obtained from the University’s Registrar’s office, the School of Clinical Medicine, the Provincial Department of Health and from the Medical Managers of the hospitals in which observations were conducted. Written, informed consent was obtained from the participants of the in-depth interviews and their engagement in the research process was voluntary.
The findings presented below are covered under the headings of the major themes that were identified.
Disinterest in teaching and marginalisation of students.
A perception of apathy towards teaching on behalf of clinical teachers, exclusion and humiliation of students and race and gender prejudices in the clinical setting were themes that emerged regarding students’ negative experiences of hierarchy.
Students felt unwelcome in the clinical setting as they perceived their teachers to be disinterested in teaching.
One student recalled what was said at orientation before her first clinical exposure in third year, here the student describes what he/she perceives to be an explicit display of apathy on behalf of the clinical teachers.
‘[The consultants] said… “this is Med-school survivor edition, you must survive. There is no time for you- you just fit in where you can… we’re not committed to your learning.”’ (I001) [Interview number 001]
Similarly, students felt excluded in the clinical setting, alluding to the hostility of the learning environment.
‘…you’re made to feel like an annoyance…. They give you this sense of “why are you here?”, like “why are you here bothering me?”’ (I002)
‘They step in front of you or physically push you out the way so they can be right at the bedside and not let you see anything or look at results or discuss anything with you’. (I011)
This theme resonated in the participant observations, in this particular observation, the clinical teacher’s reaction to a student’s request to observe a consultation serves to increase the power gradient between student and teacher by means of humiliation, marginalisation and enforces the perception of disinterest in teaching.
Dr AJ (consultant) is visibly upset, she tells Sr C (nurse), in front of the doctors and students that she doesn’t want to consult with a student observing, because, ‘they don’t read, they ask stupid questions and they get in the way.’ (PO09) [Participant observation record number 09]
Humiliation of students.
Students described incidents of humiliation, verbal abuse and physical intimidation. They felt that this negatively affected their ability to understand concepts, it enforced the hierarchy between student and teachers and added to the apprehension students felt in approaching their teachers.
‘I have been sworn at and kicked out of ward rounds for asking too many questions or standing too close to the bed where the consultant is working.’ (I011)
In some instances, gaps in knowledge were used to humiliate students, and this also served to increase the power gradient between the student and the teacher.
‘There are times where I have asked a question in a tutorial and the consultant will either reprimand me or tell me that I shouldn’t be pursuing medicine with that type of thought processing.’ (I001)
Another student reflected on the long-term effects of this humiliation.
‘…You can’t break someone down. You don’t know what type of human you are breeding once you have broken them down.’ (I004)
Students also recalled instances where verbal abuse and humiliation had escalated to physical intimidation. The following interaction left the student feeling physically unsafe in the learning environment. This sort of interaction wold serve to reinforce hierarchy, by stripping the student of his/her power and leaving him/her feeling helpless.
‘I was sworn at in front of the patient… The patient tried to interject, the doctor reprimanded her… and banged on the table and actually broke a physical… comfort zone and was in my space.’ (I005)
Black African students felt more marginalised and victimised than their other colleagues and perceived greater privilege afforded to white and Indian students.
‘[The] consultant did not teach us at all, we were all black [Africans] in the group but when I moved in the following block … there were more Indians and coloureds and there were two or three black [Africans] and we were actually actively taught.’ (I004)
This perception of privilege appeared to be appreciated by clinical teachers as well as by students. Here, the student recalled an interaction during a bedside tutorial between a black African student and a black African consultant where the consultant admonishes the student for sub-par performance, the consultant goes on to explain that the student need to work harder to achieve the same results as his/her Indian and white peers.
‘The consultant said to him in Zulu, “you’re not one of the people that comb their hair with their hands. [Here referring to Indian and white people] You’re disappointing us and you’re essentially going to fail. You don’t have an uncle in the system that is going… to privilege you to pass. [When] you do that in an exam you are going to fail… You are black and you’re not Indian… or white so you would have failed this case on [that] basis. Do not make this mistake”.’ (I004)
Some students described a perception of discrimination based on their physical appearance. This student felt that she was being subtlety discriminated against because of the texture of her hair, and her race.
‘I’m mixed [race]. I have curly hair and wear it in a ponytail. I’ve been told it is unprofessional, and to pin it up, whereas the other Indian students on my team would come with dishevelled hair that’s down in their face, but not be reprimanded for that. During ward rounds, I’ve had seniors ask me where I’m from, and mention stereotypically mixed-race areas…’ (I011)
Similar generalisations were noted during the participant observations, in this case, an Indian senior doctor was speaking to a ‘coloured’ student at the bedside of a mix-race patient during the ward round. In this interaction, the teacher humiliates the student by use of racial stereotyping and humiliation. This sort of othering increases the level of hierarchy.
‘Why can’t you just use your brain? You should know the common causes of a cardiac disease in your Woodland’s connections. The man is obviously an alcoholic. Just ask (Sr C) she can tell you all about your people.’ (PO09)
Woodlands is a historically traditional ‘coloured’ residential area.
Students described sexual discrimination and harassment in the workplace. Female staff were perceived to be less knowledgeable than their male counterparts.
‘…A female consultant wouldn’t be taken as seriously as a male consultant in their teams…. The male registrar would be favoured…’ (I009)
Female student felt objectified, marginalised and felt as though they weren’t been taken seriously in the clinical setting.
‘Medicine is still largely populated by males and they make it difficult for you in the workplace. They… make inappropriate jokes and “put you in your place” and don’t hear out your opinion even if… you’re well prepared, have done enough reading and research to join the conversation as part of a team’ (I011)
‘…we were a group of three females and soon as we entered automatically that was commented on; and we were told we weren’t in the right place.’ (I012)
In the participant-observations, sexism was often overt. The following interaction occurred during an academic ward round between a black student and an Indian consultant (AJ). The consultant condescendingly implies that the student’s ambition to become a cardiologist is unachievable and that the student should aim to be a cardiologist’s wife.
[Student AO says that she finds cardiology very interesting. Dr AJ and the two medical officers laugh together before AJ responds, ‘Cardiology? And you don’t even know how to calculate ejection fraction? My darling, you’re a very pretty girl. Aim a bit lower and maybe you’ll marry a cardiologist.’] (PO12)
The effect of hierarchy
Hierarchy was perceived to negatively affect self-confidence. This student describes how the system of hierarchy in the clinical setting made him/her feel inferior.
‘I think the hierarchy system it makes me a lot less confident. I feel inferior before I even say anything.’ (I012)
One student began to reconsider studying medicine.
‘It does definitely take a knock on your confidence and it does make you actually consider the sort of profession that you are in’ (I005)
Relationship with the patient
Patients were often witness to the dynamics between students and clinical teachers and some students felt that this affected their learning, because when patients had lost faith in them, they would refuse to allow students to examine them.
‘…When you’re just trying to introduce yourself, and [ the patient would say], “I saw you and [you were] being shouted and [you are] not a good student doctor, I don’t want [you]”’ (I006)
Conversely, students felt that their low place in hierarchy made them more relatable to patients.
‘It… brings you closer to your patients… patients… know you are at the bottom of the food chain, a large majority of them feel that they can associate with you more than they can with the senior doctors’ (I011)
Perpetuation of hierarchy
Hierarchy was accepted and enforced amongst students. Students in the clinical years had their own hierarchical system based on seniority. There appeared to be a power gradient where final year students to fourth years,
‘It’s one thing to be ahead of someone in terms of progressing in your studies and … to have the seniority over them but not make them feel it… You can be a sixth year and still be nice to a fifth year as opposed to be a sixth year who is just like, “shut up and stop bothering me” …’ (I002)