Natl. J. Physiol. Pharm. Pharmacol. (2025), Vol. 15(1): 54–57

Original Research

10.5455/NJPPP.2025.v15.i1.9

Role of early clinical exposure in first-year medical education as an adjunct to conventional didactic teaching

Ayaskant Sahoo¹ and Swikruti Behera^2,*

¹Professor & HOD, Department of Anesthesiology, Netaji Subhas Medical College, Jamshedpur, Jharkhand, India

²Professor & HOD, Department of Physiology, Manipal-TATA Medical College, Manipal Academy of Higher Education, Manipal, India

*Corresponding Author: Dr Swikruti Behera. Professor & HOD, Department of Physiology, Manipal-TATA Medical College, Manipal Academy of Higher Education, Manipal, India. Email: swikruti.behera [at] manipal.edu; drswikruti [at] gmail.com

Submitted: 09/10/2024 Accepted: 03/12/2024 Published: 31/01/2025

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ABSTRACT

Background: Competency-based medical education includes early clinical exposure (ECE) to increase understanding and concept-building in the first phase of medical education. ECE does not replace basic sciences and conventional teaching but rather enriches and contextualizes that learning.

Aim: To assess the importance of ECE in the first MBBS medical training session when taught as an adjunct to conventional didactic lectures.

Method: We started with didactic lectures on a specific topic in electrocardiograms (ECGs) followed by ECE on the same topic. This was done in a hospital setting with real patients. We obtained approval from the institutional ethical committee, and students were included in the study after signing a consent letter.

Result: The students returned a completed questionnaire after the didactic lecture, and the same students returned the questionnaire after an additional session of ECE. The students here acted as their own controls. Paired t-tests and Wilcoxon tests were performed, which revealed that the results were highly significant (p<0.001).

Conclusion: ECE was perceived as very satisfactory by the students, and it helped improve the building concept, clarity in the usefulness of the classroom, and theoretical teaching. This will also spike their interest in the subject in the long run. ECE might prove to be instrumental in bridging the gap between theory and practice from the beginning of medical education if it is executed properly.

Keywords: Early clinical exposure (ECE), Didactic lecture, Medical education, Competency-based medical education, CBME

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Introduction

The development of analytical and practical foundations in the first year of medical school in India is often hindered by the gap between clinical and preclinical teaching, which arises from traditional medical education methods. To address this issue, the concept of early exposure to clinical cases and scenarios was introduced as part of the new medical curriculum (Govindarajanan et al., 2018). However, this shift has sparked a debate about whether it may divert attention from foundational teaching to solely focusing on clinical cases, potentially leading to confusion among students and overburdening the faculty. It is also well-known that passive observation offers minimal retention and understanding (Medical Council of India, 2019). Consequently, competency-based medical education (CBME) was implemented to realign medical education with current societal needs and practices. Students should gain a solid understanding and practical experience in their subjects right from the beginning of their studies. Before 2020, first-year MBBS students in India had no clinical exposure. However, with the introduction of early clinical education as part of the new CBME system in 2020, this changed. Various studies have shown that early clinical exposure (ECE) is an effective teaching and learning method (Ewnte and Yigzaw, 2023; Phalgunan and Baskaran, 2022; Ashraf et al., 2022). Nevertheless, no research has demonstrated how integrating ECE with conventional learning can enhance its effectiveness. This study aims to evaluate the importance of combining traditional didactic teaching with closely timed ECE and assess its overall effectiveness.

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Material and methods

This study is a nonrandomized interventional study conducted at the NRI Sciences in Visakhapatnam from January to February 2022, following approval from the institutional ethics committee. The study involved a didactic lecture on electrocardiography followedby a live demonstration at the Anil Neerukonda Hospital, Visakhapatnam. The protocol for the study was developed through departmental discussions and guidance from subject matter experts. A questionnaire was created and validated by peer experts. Then it was given to the subject experts as well as statistics experts to assess the questionnaire for the understanding of the topic, teaching structure, teaching content, and student interest. The questionnaire was corrected as per the suggestions. It was aimed to highlight the clinical and logical importance of the subject. Scoring was done using a Likert scale (1–5), and the questionnaire consisted of 15 questions, without any negative or openended questions, with a maximum score of 75 points.

The questionnaires were distributed to 150 MBBS students, and responses were collected after the didactic lectures on electrocardiography. The responses obtained were coded and stored for future reference. In the same week, all the students were taken to the hospital where ECG recording, and interpretation were demonstrated on patients without and with various heart diseases. They were given various exercises like calculating heart rate, intervals, segments, and vector axis calculation. The same questionnaire was distributed among the students for them to be filled. They were coded again keeping the previous coding in mind. Out of a total of 150 students, 2 did not provide consent, 5 were absent in either one of the classes and 6 questionnaires were incomplete. So, after excluding 13 responses, we had 137 filled questionnaires with 15 questions, without any negative or open-ended questions, with a maximum score of 75 points.

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Results

Out of 150 students, 137 completed questionnaires were obtained. Among them, 82 were females, and 55 were males. Each student acted as their own control. The data obtained from the total scores of the completed questionnaires were entered into an Excel spreadsheet. The statistical analysis was conducted using the Jamovi software (The Jamovi Project, 2022; R Core Team, 2021).

Table 1 shows that the mean score for females was 61.7 ± 8.838 before ECE, which increased to 63.8 ± 8.249. The mean score of male students was 57.5 ± 9.261 before ECE, which increased to 60.7 ± 8.826 after ECE. The median ages of the males and females were 18.7 and 18.4 years.

Data on the normality of distribution, before and after ECE score is presented in Table 2. As per the Shapiro-Wilk test, the female students were not following the normal distribution curve in their ECE scores which is significant, whereas males were following a normal distribution pattern, and it was not statistically significant (p<0.05 is significant). Paired t-tests and Wilcoxon signed-rank tests were both performed, as the normality test showed that the female data were nonparametric, whereas the male data was parametric. The results were highly significant for both tests (Table 3).

Table 1. Descriptives of the students and subject scores.

Table 2. Normality of distribution before and after ECE score.

Table 3. Paired t-tests and Wilcoxon signed-rank tests between the scores of students before and after ECE.

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Discussion

As an educational model, ECE has been adopted by many medical colleges and universities worldwide to bridge the gap between the early theoretical years and clinical postings of the final year of undergraduate medical education (Shah et al., 2016). Rapid changes are occurring due to the increasing demand for services, heightened awareness, and improved accessibility for a larger population. ECE is a teaching and learning method that introduces medical students to patients as early as their first year in medical college. Research studies conducted globally have examined the impact of ECE and found that it motivates medical students improves their clinical and communication skills, and boosts their confidence (Başak et al., 2009). While ECE has proven to be an effective method for enhancing understanding and concepts, it does not replace traditional teaching methods. It is most effective when combined with didactic lectures that integrate theoretical knowledge with hands-on practice. This approach helps establish a solid foundation in medical education beginning in the first year of training. Our findings indicate that ECE implemented after didactic lectures resulted in significant differences (see Table 3). According to Tayade (), ECE can be an effective measure for undergraduates if it is correctly implemented (Tayade and Latti, 2021). Some researchers have found that ECE makes medical education more comprehensible to students (Miglani and Arora, 2020; Littlewood et al., 2005). Gupta et al. (2020) discovered that utilizing ECE proved to be a more effective learning tool, leading to enhancements in knowledge retention, attention, and motivation. Researchers have found that students believe clinical exposure, combined with classroom knowledge in ECE, helps in the better application of practical physiology (Nanaware and Gavkare, 2020; Deolalikar et al., 2020). Several studies have shown that ECE can increase interest in learning. Correct implementation of teaching-learning methods is very essential for them to be successful. However, in many European countries, the implementation of this approach has been unsuccessful after almost 15 years. This is due to fundamental issues such as lack of institutional interest in certain disciplines, unwillingness to experiment, poor orientation, and heavy workloads (Simmenroth et al., 2023). While innovative methods can be beneficial, they tend to be more effective when combined with traditional approaches and implemented at the appropriate timefor the right competencies. ECE is a well-consideredteaching and learning strategy that should be adoptedwith an awareness of the existing workload and staffavailability in various institutions. It is crucial tocarefully select competencies for ECE, ensuring thatthey are standardized across colleges nationwide toprevent failures related to implementation.

Our study is limited by its small and nonrandomizedsample. Adding an assessment to interpretconcept building might provide better insight.Qualitative feedback was not collected.

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Conclusion

Our study underlines the importance of clinical exposurewhich increases the effectiveness of teaching basicsciences in medical education. The first year is whenstudents build a strong theoretical foundation. Whiletraditional classroom teaching is important for phaseone students for theoretical and cognitive development,integrating clinical exposure allows for a deeperunderstanding and practical application of the subjects.This approach may help students learn and understandthe topics better and will enable them to apply theirknowledge when needed by using innovative teachingmethods. It’s time that we understand that only newteaching-learning methods cannot improve the qualityof medical education; correctly implementing them isalso equally important.

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Acknowledgment

We thank all the NRIIMS students who participatedin the study. We also appreciate the contributionsof our peers and experts, who helped us validate thequestionnaire.

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Funding source

Nil.

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Author contributions

Both authors contributed equally to conceptualization,data acquisition, statistical analysis, manuscript editing,and proofreading.

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Conflict of interest

Nil.

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Data availability

Yes (DOI:10.17632/tmn3dzzd3c.1).

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REFERENCES

Ashraf, R.R., Choudhary, S. and Tandon, V.R.2022. Comparative study to evaluate the role ofproblem based learning method vs conventional teaching method in medical education. JK Science 24(4), 235–238.

Başak, O., Yaphe, J., Spiegel, W., Wilm, S., Carelli, F. et al. 2009. Early clinical exposure in medical curricula across Europe: an overview. Eur J Gen Pract 15, 4–10.

Deolalikar, Suchitra; Nandi, Jayshree1; Pramod, John. 2020. Introduction of Early Clinical Exposure to 1st Year MBBS Students in Physiology. Chrismed J Health Res 7(1): 63–67.

Ewnte, B. and Yigzaw, T. 2023. Early clinical exposure in medical education: the experience from Debre Tabor University. BMC Med Educ 23(1). Available via https://doi.org/10.1186/s12909-023-04221-4

Govindarajanan, S., Vasanthb, G., Kumarc, P.A., Priyadarshinib, C., Radhakrishnand, S.S., Kanagaraje, V. et al. 2018. Impact of a comprehensive early clinical exposure program for preclinical year medical students. HealthProf EdU 4, 133–138. Available via https://doi.org/10.1016/j.hpe. 2017.06.002

Gupta, K., Gill, G.S. and Mahajan, R. 2020. Introduction and implementation of early clinical exposure in undergraduate medical training to enhance learning. Int J Appl Basic Med Res 10(3), 205–209. Available via https://doi.org/10.4103/ijabmr

Littlewood, S., Ypinazar, V., Margolis, S.A., Scherpbier, A., Spencer, J. and Dornan, T. 2005. Early practical experience and the social responsiveness of clinical education: systematic review. BMJ 331, 387–391.

Medical Council of India. 2019. Early Clinical Exposure for Undergraduate Medical Education Training Programme. pp: 1–43.

Miglani, A.K. and Arora, R. 2020. Introduction of early clinical exposure (ECE) in 1st year MBBS students in the department of physiology. Int J Physiol 8, 9–14.

Nanaware, N.L. and Gavkare, A.M. 2020. Impact of early clinical exposure to boost the applicative aspect of learning among first MBBS physiology students. Natl J Physiol Pharm Pharmacol 10(02), 141–143.

Phalgunan, V. and Baskaran, S. 2022. Evaluating the effectiveness of early clinical exposure program in learning clinical anatomy among medical undergraduates. Acad Anat Int 8(1), 12–15.

R Core Team. 2021. R: A Language and Environment for Statistical Computing (Version 4.1) [Computer software]. Available via https://cran.r-project. org. (R packages retrieved from MRAN snapshot 2022-01-01).

Shah, N., Desai, C., Jorwekar, G., Badyal, D. and Singh, T. 2016. Competency-based medical education: an overview and application in pharmacology. Indian J Pharmacol 48, S5–S9.

Simmenroth, A., Harding, A., Vallersnes, O.M., Dowek, A., Carelli, F. et al. 2023. Early clinical exposure in undergraduate medical education: a questionnaire survey of 30 European countries. Med Teach 45(4), 426–432. Available via https://doi.org/10.1080/0142159X.2022.2137014

Tayade, M.C. and Latti, R.G. 2021. Effectiveness of early clinical exposure in medical education: settings and scientific theories – review. J Educ Health Promot 10, 117. Available via https://doi.org/10.4103/jehp

The Jamovi Project. 2022. Jamovi. (Version 2.3) [Computer Software]. Available via https://www.jamovi.org.