The central concern of the thesis is to problematise the complexity of the relationship between student learning and the teaching-learning environment in medicine as experienced by students. The thesis argues that learning material presented to students offers only potential for learning. What students make of that potential is influenced by a number of different variables and as such this needs to be investigated empirically. High-quality learning is an important goal for all higher education and previous research together with the empirical findings presented in this thesis convey the importance for students to seek a holistic approach to learning. Such a learning approach encompasses not only learning of facts and theories but also includes exercising an ability to reflect and reason, to organise facts and theories into wholes, and to explore how they relate to each other. Most importantly, it involves the ability to understand the grounds on which facts and theories are chosen for specific purposes depending on context. The thesis explores these issues by drawing on findings from three studies of medical students’ experiences of learning and understanding and how students’ personal understandings of subject content in medicine come to the fore in their work on learning tasks. By applying a context-oriented methodological perspective on learning, focusing on what students actually do in a learning situation, the thesis enables an in-depth investigation of relationships between aspects of content, context and the individual. The results show that the learning environment in the medical programme to a large extent does not make sufficient room for students to express understanding of this dynamic character. In the thesis it is argued that to facilitate such an understanding it is necessary for both students and teachers to increase awareness of the context-dependency of subject content, facts and theories, and the different meanings content takes depending on context of use. 

The study investigates medical students' ways of approaching a medical task. Fourteen medical students in their clinical years responded to a written patient case on chest pain. Variations in the students' responses to the task were analysed from a contextual and linguistic perspective. Students approached the task in two distinctly different ways. Either they treated the task as a problem situated within a purely academic context-listing concepts relevant to the symptom, applying the steps in the diagnostic process only once-or dealt with the task as a problem contextualised within a hypothetical clinical situation-testing alternative meanings of the symptom, elaborating on implications for the patient. It is not students' conceptualisations of medical theory that explain these outcomes but rather how students construct contexts in which these conceptualisations are embedded. The results highlight the importance of being sensitive to what students make of a given task, how their interpretations relate to what was intended by the teacher, the desired outcome of the curriculum, and the influences exercised upon students by the various educational settings confronting them in their studies.

This paper draws on ongoing work into student learning in higher education to consider a basis for conceptualising students' experiences of understanding in medicine. Starting with a modest overview of research on the nature of students' experiences of understanding the paper goes on to consider research on students' personal understandings in terms of knowledge objects. Linking on to research on students' epistemological beliefs the paper forges connections to recent research on threshold concepts and related research on conceptual change. Against the background of this brief overview the paper surveys the research on medical education, and then draws on interview data, currently being collected in a Swedish research project to offer a preliminary conceptualisation of students' experiences of understanding in medicine.