What influences student experience of Graduate Entry Medicine? Qualitative findings from Swansea School of Medicine

Abstract

Background: The Graduate Entry Programme (GEP) in Medicine delivered by Swansea University (currently in collaboration with Cardiff University) accepts students from a diverse range of academic backgrounds with no restriction in relation to the field of first degree. There is a growing body of literature, predominantly quantitative in nature, regarding the influence of academic background on student achievement but little published information on students’ views.

Aim: To examine students’ views regarding the extent to which previous higher education and wider life experience influence their student experience on the GEP course.

Method: Recruitment from three student cohorts and group interview data followed by descriptive thematic analysis of anonymized data.

Results: Data themes were: (1) previous study experience and its impact on present student experience; (2) the impact of life experience; (3) the impact of the present study on life experience; (4) skills, status and difference; (5) characteristics and expectations of the course; (6) finances and (7) next steps. Previous study experience had little impact on present student experience. However, previous life experience, with time between first degree and GEP, clearly enhances the learning experience. Added maturity and early clinical contact enables students to manage the challenges of the course and the NHS environment despite financial strain and heavy coursework.

Conclusions: Analysing students’ views is informative and provides richer insight into experience and expectations than that accessible from quantitative data alone.

Introduction

Graduate Entry Programmes (GEPs) in medicine are relatively new in UK medical schools. Swansea University's School of Medicine enrolled its first cohort of GEP students in 2004 on a four-year programme, currently delivered in collaboration with Cardiff University. These students, and subsequent cohorts, have a diverse range of backgrounds in terms of the subjects of their first degree and subsequent educational and life experiences.

A growing body of the quantitative literature suggests that, while some differences exist between graduate and non-graduate entrants in assessments of knowledge and skills, these differences are marginal and decrease as the course progresses (Craig et al. 2004). The qualitative evidence that exists largely focusses on whether graduates make ‘good doctors’ (Gapper 2006), or evaluates problem-based medical curricula (Dickman et al. 1980; Jones et al. 2002; Dean et al. 2003; Hayes et al. 2004), but no studies have explored the range of influences from first degrees and other life experiences on GEP students.

Swansea's current policy is to recruit graduates with first degrees from any discipline with a first or upper second class. Inevitably entrants differ from one another, not only in degree topic, but also in wider ‘life experience’, age and maturity. Several have further degrees at masters or doctorate levels, some already have established professional careers and some have family and financial commitments.

We examined the opinions of GEP students about their studies and previous experience, involving student researchers recruited from amongst the GEP cohorts trained and supervised by us in participant recruitment, questionnaire completion, interviewing and analysis of extensive qualitative data. The overall aim was to examine students’ views across four GEP years to gain an understanding of the extent to which previous higher education and life experiences influenced their experience of GEP studies.

Table

Practice points

Previous work and life experience provide GEP students with the skills necessary to cope with the pressures and demands of the course and engender hard working, motivated and closely knit cohorts. GEP students are noted for their ability to communicate, their confidence and self-assurance and determination to succeed in their studies. Differences in first degree in arts-based or science-based topics have no long-term effects on studies, progress with the course or ability to succeed. Previous life experience including high-flying careers and family responsibilities enhance students’ functioning within NHS placements, early patient contact and communication with health professionals. Students struggle to adjust to financial pressures, different lifestyles and lack of time for family and friends and are worried about achieving a positive work–life balance which influences their views of the medical profession and decisions about future work pursuits.

Methods

Recruitment

Students were recruited from across three cohorts, enrolled in 2004, 2005 and 2006 – a total of 184 students. The lead student researcher (SF) contacted students by letter and sent them an information pack. They were asked to complete a questionnaire and whether they would be prepared to attend a one-hour, semi-structured, group interview with others in their year group. The consent forms emphasized anonymity and confidentiality of the interview process. Thirty-four students returned questionnaires with free-text entries that could be used to inform the interview schedule. A larger number signified willingness to be involved in interviews.

Interviews

Group interviews were chosen to enable students to elaborate upon a broad range of questions, with opportunities for some topic diversification. Group interviews are particularly helpful with established groups, where individuals are well known to one another, and are often held with smaller groups of participants than would be the case with, for example, focus groups (Robson 2002). Group interviews differ from focus groups in that the former has less interaction between participants than the latter. This was appropriate in this case, in that it was the views of each student that was the focus rather than those formed by discussion between them.

Data collection was carried out while the students were in their second and third years, overseen by the lead student researcher monitoring the work, ensuring continuity of process and consistency of data collection. Other student researchers worked together facilitating the sessions and observing group dynamics. Interviewers interviewed students from a different cohort to their own, and none of the interviewers were themselves interviewed.

Interviews were conducted according to an agreed protocol and complied with University ethical and governance rules of conduct. At the outset, participants were randomly assigned an alphabetical letter to preserve anonymity and enable quotations to be attributed. All interviews followed a pre-defined schedule (Figure 1) based on the current literature and findings from the questionnaires and were tape-recorded and transcribed.

Figure 1. Interview schedule.

Ethical aspects of the study were discussed at the Joint Scientific Review Committee of the Swansea NHS Trust and Swansea School of Medicine. It was decided that, provided student anonymity was preserved, there were no ethical constraints to the study.

Analysis

The study team (students, researchers and senior academics) considered the qualitative data through four group analysis sessions. The initial session clarified the most appropriate analytic framework whereby the group would work iteratively towards a descriptive thematic analysis (van Manen 1990, 1997; Robson 2002; Denzin & Lincoln 2005). The other three sessions clarified the major themes derived from the data and their content. To begin the process a senior academic with expertise in qualitative research methods (FR) and the study lead (RW) undertook preliminary analyses of their own, leading to a number of working thematic headings. Though unusual, the rationale for this was that many members of the research team had no qualitative data analysis experience and needed guidance. (As the group analysis proceeded, many of the initial categories did change and were refined into a final set of themes.)

The eight transcripts were divided within the group, with random pairs of analysts ascribed the same three transcripts. Each person also took responsibility for analysing their own three transcripts, coding them and writing ‘descriptors’ of thematic headings. Issues of note were marked down with concomitant quotations and pairs then worked together to confirm each other's understanding of the data (van Manen 1990, 1997). Analysts prepared a well-crafted, detailed defence of their interpretation, which was discussed and refined during the final group session (Bowling & Shah 2005; Denzin & Lincoln 2005).

Figure 2. Working thematic headings used in the analysis.

Results

Eight groups of four to seven participants took part in the study, each with a mixture of arts-based and science-based backgrounds (Table 1). Of the 44 students who took part, 27. Around a third of these were arts graduates and each group had a mixture of arts and science graduates. The findings below (see Figure 2 for list of themes) highlight students’ views relevant to each of the headings listed in Figure 1 and include verbatim quotations identified according to the interview group number (1–8), and interviewee identification letter (A, B, C, etc.).

Table 1.  Group characteristics of eight student group interviews

Group interview no.	Date of session	Year of entry of student cohort	Year of study	No. of participants
1	11/07/07	2005	2 (end)	5
2	11/07/07	2004	3 (end)	6*
3	16/07/07	2004	3 (end)	5
4	17/07/07	2004	3 (end)	5
5	19/07/07	2005	2 (end)	7
6	23/07/07	2006	2 (beginning)	6
7	12/12/07	2006	2 (beginning)	6
8	12/12/07	2006	2 (beginning)	4

Note:*one participant was late in joining the session.

1. Previous study experience and its impact on present study experience

The previous study experience, be it for an arts-based or science-based degree, engendered a hard working, focussed, motivated and closely knit group across cohorts who recognized the exacting demands to the course. Interviewees were resigned to working hard: ‘I noticed how driven people were, you could go to the library any time of day or night and there’d always be someone there from the course’ [5C], seeing themselves to be less likely to be caught up with other distractions than those undertaking undergraduate degrees.

Interviewees also described finding medicine a lot harder than their previous degree. Nevertheless, previous study enabled them to recognize different approaches to working and to work out a method that suited them, moving from one style of working to another with flexibility and versatility. Science-based first degrees, such as those in Biology, Chemistry and Zoology, were said to give students an ‘edge’ at the beginning of their post-graduate studies, enabling them, for example, to take on board and apply knowledge regarding anatomy and physiology more easily: ‘I did genetics and some of the underlying science … really … I just had some of the language before’ [5D]. However, the edge quickly disappeared, as arts-based students began to apply themselves as competently: ‘I felt we were all on an even playing field in a few months’ [5F]. Students had anticipated that having a science degree would be more useful than it turned out to be, and its scope was seen as limited: ‘Neuroscience was very useful when doing neurology, and slightly useful in a few other areas, but really beyond that, not much help at all’ [2B]. In addition, arts-based students’ experience of different writing styles stood them in good stead for essay writing and critical and analytical writing: ‘I found the essays really difficult coming from a chemistry background. I can’t remember ever writing essays always my work was continuous assessment’ [5B] and, ‘My friend, he did an arts degree and I remember him reading one of my essays and just laughing at the word structure’ [5D].

2. Life experience and its impact on present study experience

Previous life experience impacted extensively on GEP study experience, especially when it came to history taking, examining patients and understanding concepts such as consent, confidentiality, reflective practice and professionalism. Those who had had time out between studies saw this as a welcome break: ‘It made me have time to think about what I wanted to do’ [4B]; ‘If I had gone to do medicine first, I would probably have found it a lot harder’ [6B] and, ‘My year out was more useful than my whole degree put together’ [6E].

However, some students experienced difficulties getting back into an academic frame of mind and thought going directly on to a second degree made a lot of sense: ‘I just wanted to get on with it really’ [4C]. Whilst some students having a gap year did describe feeling slightly lost, those moving directly from undergraduate study to this course also had reservations, saying they would have liked more time to review their situation.

Those with previous work experience within primary, secondary, hospice or home care commented on how the different NHS environments supported their expectations of the course: ‘My degree wasn’t the most helpful, but working in hospitals, yeah definitely’ [4A]. Several students who had worked in positions of responsibility were used to being seen as professionals: ‘I’ve got a lot more confidence coming into this degree than the last and I look at problems in a different way; partly due to a previous job’ [4C]. Some students had family commitments and added children and financial responsibilities to their list of things to consider in relation to the present study. Furthermore, previous experience gave them increased skills to cope with early patient contact: ‘Speaking to patients wasn’t really a problem’ [8B], whilst caring for relatives or friends gave considerable insight into the workings of the NHS.

3. Impact of the present study on life experience

Whilst valuing their time as medical students, participants expressed some resentment at ‘missing out’ on the life experiences which they felt former co-students, from previous degree programmes, were now experiencing: ‘I would always look at my friends that went off into the business world and thought: ‘Why am I here?’ I could have gone off and had this amazing job’ [2G]. This resentment centred, not only around job satisfaction but around remuneration, perceived freedom to enhance their careers and elevation in status: ‘I’ve gone straight from my first degree to my second degree. All my friends have qualified at least a couple of years and they’re all earning and talking about getting promotions and things like that and I do feel a bit left out …’ [4D]. Leisure time, at weekends, holidays and in the evenings was seen as severely curtailed due to the intense programme of study: ‘On a weekend, come five o clock Friday they’re free whereas a lot of weekends [sic] you have to sit down for at least a couple of hours and do something. When everyone wants you to go on holiday or go up the pub you know you have to sit at your desk, that's really hard’ [3D].

Difficulties about seeing friends were compounded by what they saw as the relative isolation of Swansea: ‘I would have been really scared if I’d actually thought properly about what moving to Swansea meant for all my friendships and relationships … the nearest person that I knew well before I settled in here was about 3 hours drive [away]’ [1B]. Whilst staying in touch had cost implications, maintaining friends from ‘outside medicine’ was important: ‘It can get incredibly claustrophobic spending … all my time in lectures and in hospitals with medics’ [1F].

4. Skill, status and difference

Participants felt isolated from other students on other courses and set apart from peers through their privileged position, differences in age, experience and status. The cohorts therefore stuck together, separated from others around them, but confident within themselves. This, they said, was noticeable in the strong group-working ethos that built up over their time and their ability to apply themselves to an intensive workload. Participants described a wide range of interests, experiences and skills to be drawn upon, especially during small group work sessions. Moreover, differences in ability and standing and between those from arts- and science-based backgrounds only added to their strengths – enhancing group performance through shared experience.

A number of participants described professionals’ negative views during their placements in hospitals, but in spite of this, students were noticed for their confident, mature attitude and for speaking their mind and were respected for this. Furthermore, students learnt from one another and were keen to ask questions and understand clinical situations. They felt at an advantage over undergraduate medical students when it came to inter-personal skills, and used these skills successfully in practice, making the case that competence in communication and practice is vital for good professional–patient relationships.

They described the rigours of the course as something not to be underestimated. Previous work experience, especially at the level of managerial work made it easier to approach senior colleagues: ‘you are more likely to open your mouth’ [7F], but at the same time more difficult to take orders from others: ‘you do feel a bit “don’t patronise me”’ [2C]. As a consequence, students felt they were sometimes misjudged as being aloof or superior. Students who lacked certain skills felt supported appropriately during their studies through the offer of one-to-one sessions with tutors: ‘there were people I could go to if I had a problem’ [2A], whilst early clinical contact encouraged students to actively put their learnt skills into practice: ‘It was partly what attracted me to the course … to get your hands dirty in the first week’ [5B], ‘this is really cool, this is what I want to do’ [8A].

5. Characteristics and expectations of the course

Despite the publicity material, school open days, interview information and ad hoc enquiries, knowledge of what to expect from the course was vague and only really confirmed when students had enrolled: ‘… because it was a new course you didn’t really know what to expect’ [3A]. Some students focussed on gaining access to the course rather than on what it would entail: ‘I didn’t really think about it! I was too focused on getting in and then I would think about what it was like once I got there … I was willing to go through whatever it took’ [1B].

Other participants had clear expectations and a rationale for choosing Swansea over and above other courses: ‘I actually looked at the courses before I applied. I compared all the courses and the number of contact hours … when I would be seeing patients … I chose this course because we would be seeing patients very, very quickly, whereas other courses you don’t see them for the first year, or more … With all the coursework and all the lectures, I actually needed that contact to remind me why I was putting myself through this’ [1F].

Thus, the early and frequent contact served as something of an antidote to the grind of lectures and formal coursework. Inevitably there were differences of opinion regarding the degree to which the course was intellectually challenging: ‘… it's far less complicated than science. I’ve been really quite surprised by it’ [2B]; ‘… there's such a breadth of information and skills that you have to try and pick up in a short amount of time’ [5D] and recognition that, as well as skills in understanding, processing and memorizing information, other demands abound: ‘… as well as learning new information you have to be a good people person’ [5D].

6. Finances

There are many financial disincentives for the medical student and the GEP course is acknowledged as costly. In addition, leaving a well-paid job for an extensive period of study means a reduction in income and a dramatic life-style change: ‘You have the car, you have the tastes, you have the friends and you have that circle’ [7B]. Participants commented on the course's financial exclusivity: ‘Financially the course is ridiculously hard and I think it's really [exclusive]’ [1B] and on being financially estranged from friends who are perceived as being at an advantage. In addition friends have pursued a career path with a clear trajectory, whilst they have concerns about their own. This is particularly the case as large overdrafts or loans build up: ‘I’m struggling, and I’ve had to take out a bank loan’ [3D]. Loans can be up to £45,000 by the end of the course, making it difficult to manage, even with job prospects at the end: ‘I’ve got about forty five grand-worth of debt … I’m doing day-to-day living’ [3D]. However, financial difficulties did not stop these students pursuing the GEP course: ‘You find ways’ [3A], and the thought that at the end of their studies they will be able to hold down a well-paid job as a doctor made studying with a loan worthwhile: ‘Well it's swings and roundabouts’ [7F]. Medicine is seen as being a more challenging, lucrative job than other ‘nine-to-five’ jobs, and this was a clear incentive to keep going.

7. Next steps

The students expressed concerns about the work available to them after they qualified: ‘you’ve got to worry about other things like whether you’re going to get a job’ [1A] but this was further complicated by changes in students’ ideas, concerns and expectations with regard to the speciality they wished to go in to and expectations for work–life balance: ‘It's still a bit of a dilemma … whether or not I’m kind of prepared to give up my life to the extent that I think you’d need to, to get there – neurosurgery … [1E].

Other considerations around the future concerned where they were happy to reside, finances and family life: ‘I’m getting older … I’d like to have kids’ [2C]. Apart from changes to their work over the course of the GEP, they also saw themselves as changing: In my previous life I was a very different person to how I am now [3B]. ‘I’ve certainly changed!’ [5F]

Discussion

The literature is largely devoid of qualitative studies exploring the views of GEP students regarding the influence of higher education and life in general on their student experience. In this study, group interviews allowed the research team to explore these issues in detail, involving students themselves in the study, with appropriate training and guidance from senior academic staff. The study had its limitations. For example, small numbers of group interviews were undertaken and these were run by early stage researchers. However, it did employ a fresh approach to the data and to data handling and the small numbers of groups meant that extensive working could take place to uncover rich, thick data findings.

The students learnt a considerable amount about not only the methods, but also the frustrations and limitations of carrying out research of this kind. For example, one of the proposed interview sessions did not take place due to lack of available time in participant and student researcher’ schedules. Nevertheless, the rich data acquired contributes to a deeper understanding of students’ views, expectations and concerns than would be gathered using quantitative approaches alone.

Some of the generic study skills acquired from previous degree programmes, such as essay writing, enabled students with arts-based degrees to tackle assignments with confidence and, perhaps, marginally better success than science-based degree students. Conversely, some of the subject matter of science-based degrees was of assistance in specific aspects of the programme. However, in an analogous manner to the findings of Craig et al. (2004), these effects were of little importance and did not persist for long. This is an important vindication of the original decision to recruit from across the spectrum of arts, biological science and non-biological science first degrees to enrich both the learning and teaching experiences.

In contrast to the virtually negligible effects of the field of study of prior degree, the influence of prior life experience seems considerable. Some of the comparatively few students who had progressed immediately from their first degrees to GEP commented on the advantage of being ‘in the swim’ of studying, whilst those with a gap between their first degree and GEP welcomed the time to contemplate their decision to embark on medicine and their acquired confidence with patients and professionals. Students entering straight into GEP without a gap, of course, have no way of knowing what they have missed, but our findings emphasize the importance of life experience and strongly suggest that future recruitment should highlight this benefit.

The views of students regarding the life opportunities being forgone (amazing jobs, earning well, changing jobs, getting promotions, evening and weekend leisure), personal financial burdens and perceived sacrifices needed to achieve hospital consultant status pose considerable challenges to ‘marketing’ the course and widening access to medicine. The appeal of GEP and the medical career to which it leads needs to be sufficient to overcome these social and financial sacrifices and bursaries or other financial support need to be available to ensure these opportunities are not only open to those capable of financing a hefty student loan.

These data support the view that the study of medicine involves the memorization of large amounts of facts and that the resulting workload and time pressure inhibits deeper learning as well as social activity. Students have been previously seen as a tabla rasa or ‘blank slate’ (Dewey 1997) on which the medical school can write, but GEP students clearly have their own experiences and are able to observe and make their own judgments as to the meaning of events. As Dewey noted, the totality of a learning experience depends on: ‘Everything the teacher does, as well as the manner in which he does it’ (p. 47).

This study revealed a diverse range of previous student experience, which poses a considerable challenge for medical school tutors. However, we recommend taking advantage of opportunities to gather feedback from GEP students themselves as an essential element of the successful growth and development of these courses. Although our cohorts have aired certain struggles, their extensive academic and personal achievements and dogged determination to see the course through are ringing endorsements for the decision to offer places to graduates with rich and varied backgrounds. The project proved to be a useful learning opportunity for the student researchers. Next steps are likely to include the follow-up of the Swansea/Cardiff cohorts to gauge the influence of aspects of the student experience on confidence and performance in the Foundation years and beyond.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the article.

Additional information

Notes on contributors

Frances Rapport

FRANCES RAPPORT, PhD, is Professor of Qualitative Health Research at the School of Medicine, Swansea University, Head of the Qualitative Research Unit and Co-Lead of Qualitative Inquiry Cyrmu (QUIC) an all-Wales research collaborative. She took a leading role in publication writing study design and implementation, supporting data capture and analysis.

Gwen F. Jones

DR GWEN F. JONES is a General Practitioner and Senior Clinical Tutor at Swansea Graduate Entry Medical School. She leads the Family Case Study – early clinical contact in the first year of the course. She played a major role in study design, data analysis and in drafting the article.

Shaun Favell

SHAUN FAVELL is a final year student in the Swansea/Cardiff Graduate Entry Medical Programme. His role in this study was to lead the student involvement, including planning, study design, execution of interviews, collection of data, data analysis and drafting.

Jonathan Bailey

JONATHAN BAILEY is a final year student on the Swansea Graduate Entry Medical Programme. He contributed to the recruitment and interviewing of participants, the analysis of interviews and contributed to the final report.

Laurence Gray

LAURENCE GRAY is a Foundation Year-1 doctor and graduate of the Swansea/Cardiff Graduate Entry Programme. In this study, he organized interviews, acted as facilitator during discussions and analysed data.

Alexis Manning

ALEXIS MANNING is a Foundation Year-1 doctor at Abertawe Bro Morgannwg NHS Trust, and was part of the first cohort of Swansea students. He was involved in the development of the protocol, recruitment and interviewing of participants, analysis of responses and reviewing of the final report.

Paul Sellars

PAUL SELLARS is a Graduate Entry medical student at Swansea/Cardiff Medical School. His involvement in the research project included helping with study design, holding student interviews and data analysis.

Julie Taylor

JULIE TAYLOR has recently graduated as one of the first student cohort. Her contributions included recruitment of participants, fieldwork, transcript analysis and participation in steering group meetings.

Aidan Byrne

AIDAN BYRNE is a Senior Lecturer in Medical Education at Swansea University. He contributed to data analysis and the writing of the study report.

Adrian Evans

ADRIAN EVANS is a Senior Consultant in Emergency Medicine at Morriston Hospital, Swansea and Reader in Emergency Medicine at the School of Medicine, Swansea University. He is also Clinical Module Lead for Musculoskeletal and Undergraduate Examiner for intermediate and final examinations. Dr Evans contributed to study design and analysis.

Claire Cowell

CLAIRE COWELL is the Admissions Coordinator for the Graduate Entry Medical Programme at Swansea University and contributed to the qualitative article by assisting with the transcription of audio material and commenting on drafts.

Sarah Rees

SARAH G. REES is a Lecturer in Medical Science and Admissions Tutor for Graduate Entry Medicine. She has contributed to data analyses and interpretation in this study.

Rhys Williams

RHYS WILLIAMS is Dean of Medicine and Professor of Clinical Epidemiology at the Swansea School of Medicine. His contribution was the initial stimulus for this research and involvement in each of its stages.