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 Table of Contents  
MEDICAL EDUCATION
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 63-67

Introduction of early clinical exposure to 1st year MBBS students in physiology


1 Department of Physiology, Christian Medical College, Ludhiana, Punjab, India
2 Department of Community Medicine, Christian Medical College, Ludhiana, Punjab, India

Date of Submission15-Jun-2019
Date of Decision23-Sep-2019
Date of Acceptance10-Oct-2019
Date of Web Publication19-Jun-2020

Correspondence Address:
Suchitra Deolalikar
Department of Physiology, Christian Medical College, Brown Road, Ludhiana - 141 008, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cjhr.cjhr_71_19

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How to cite this article:
Deolalikar S, Nandi J, Pramod J. Introduction of early clinical exposure to 1st year MBBS students in physiology. CHRISMED J Health Res 2020;7:63-7

How to cite this URL:
Deolalikar S, Nandi J, Pramod J. Introduction of early clinical exposure to 1st year MBBS students in physiology. CHRISMED J Health Res [serial online] 2020 [cited 2020 Jul 8];7:63-7. Available from: http://www.cjhr.org/text.asp?2020/7/1/63/286890




  Introduction Top


Physiology is foundation of medicine along with anatomy and biochemistry. If it is taught in clinical context, like providing early clinical exposure (ECE), students will appreciate the importance of the subject and will be able to integrate the subject with clinical sciences.

Medical Council of India (MCI) regulations on Graduate Medical Education 1997[1] states “Adequate emphasis is to be placed on cultivating logical and scientific habits of thought, clarity of expression and independence of judgment, ability to collect and analyze information and to correlate them.” This mind set needs to be developed. It has been observed that when physiology is taught in clinical context, the students understand and retain better. This has led to the need of integrating physiology with clinical sciences. It can be achieved by exposing the 1st year UG students to ECE as is advocated by MCI Vision 2015 document.[2] ECE in turn will also emphasize the importance of studying physiology.

It is observed that perceived clinical relevance is a contributing factor to the retention of basic science knowledge, and this requires curriculum planners to make clinical relevance a more important component of teaching throughout the medical course.[3],[4] ECE helps students to better their understanding of a particular topic, makes teaching more relevant, improves their retention power, and helps them to relate clinical conditions to basic sciences.[5] ECE improves interaction of students with others, promotes professional development, motivates them to learn more, and increases their understanding of the role they have to play as medical professional in the future.[6] It is also seen that the students find ECE valuable; it helps them remember the subject better and helps them integrate their knowledge.[7],[8] It can be summarized that teaching physiology in clinical context is the need of the hour.

ECE can be done by any one of the following methods:[9]

  1. Taking the students to hospital or to a live patient
  2. By discussing case histories, laboratory reports, photographs, X-rays, or any other clinical material
  3. Taking the students to community visits.



  Materials and Methods Top


This was a cross-sectional study. The study was approved by Institutional Research Committee. Sixty eight first year medical students volunteered to participate in the study, constituted the study group.

The department faculty was sensitized to ECE, and the feedback questionnaire was approved by them.

First professional MBBS students, who had already spent more than 5 months in the basic sciences, were sensitized to ECE by taking a lecture. The meaning of ECE, the purpose, and the methods of conducting ECE was explained to the students. The role of students as participants was succinctly explained. Participation was voluntary. Informed written consent from the student volunteers was taken. Two sessions of ECE (each of 3-h duration) were planned; one at the end of lectures on cardiovascular system (CVS) unit and the other at the end of lectures on renal physiology.

The routine CVS lectures cover the topic of cardiac output and also include lecture on cardiac failure. On completion of didactic lectures on CVS, the first session of ECE was introduced. The session lasted for 3 h.

A common case from CVS, a case of congestive cardiac failure (CCF) with pulmonary edema was selected as case for the first ECE session. After consulting the clinicians in Cardiology Department, case history, findings, and investigation reports of the patient were collected (Patient's identity was not revealed). Videos from YouTube were downloaded.

ECE session was conducted as follows:

  • Three videos showing self-narration by a patient in cardiac failure and pulmonary edema were shown to the students. In this narrative, the patient tells about what it feels to be in CCF, talks about experience of living in a hospice, and shares her thoughts about dying
  • The case history and findings of a patient admitted under Cardiology Department was presented to the students. Case history including chief complaints, history of present illness, history of past illness, family history, personal history including history of habits, and work history was discussed
  • The pathophysiology of symptoms such as fatigue, shortness of breath, anorexia, and early satiety associated with abdominal pain was discussed
  • Findings from general examination and systemic examination were discussed. Pictures of pallor, icterus, and pedal edema downloaded from net were shown to students. These terms were explained to them, and where to look for these signs in a patient was also explained
  • The pathophysiology of examination findings such as orthopnea, paroxysmal nocturnal dyspnea, increased jugular venous pressure, pulmonary crepitation, cardiomegaly, hepatomegaly, ascites, and peripheral edema was explained
  • The normal pressures in pulmonary circulation and safety factors for edema were revised. The pathophysiology of edema was explained
  • Investigation findings such as cardiac size and shape, state of pulmonary vasculature on X-ray chest, left ventricular hypertrophy on ECG and left atrium and left ventricular size, right ventricular size, and ejection fraction in two-dimensional echo was discussed
  • Students learned how to diagnose cardiomegaly from X-ray chest, calculation of heart rate from ECG, diagnosing ventricular hypertrophy from ECG and determining axis deviation
  • Pathophysiological basis of management was explained with the help of flowcharts
  • Video clip featuring epidemiology, etiology, definition, types, pathophysiology, physical findings, investigations, and treatment of CCF was shown (downloaded from YouTube).


At the end of session, the case was summarized. The importance of taking history, a thorough clinical examination, interpreting the investigation reports, and the pathophysiology of management was emphasized. The need to be sensitive to patient's suffering was explained.

Following the first session of ECE, students had the first-term examinations followed by vacation. After vacation, didactic lectures on renal system were scheduled. At the end of lectures, second session on ECE (3-h duration) was conducted as follows:

A case of chronic kidney disease (CKD) (Stage V) with fluid overload and mineral bone disease and anemia was selected. After consulting the clinicians in Nephrology Department, case history, findings, and investigation reports of the patient were collected (Patient's identity was not revealed). Videos from YouTube were downloaded.

  • Video from YouTube was shown which contained patient's story: Living with kidney disease
  • The case history and findings of the patient collected from Nephrology Department was presented to the students. Case history, including chief complaints, history of present and past illness, personal history including habits and work history was discussed
  • New terms such as hematuria and pyuria were explained
  • Findings from general examination and systemic examination were discussed
  • Investigation findings like renal function test were discussed. Abnormal values with normal values were compared. Ultrasound diagnosis of CKD was conveyed
  • Video showing pathophysiology of kidney disease (downloaded from YouTube) was shown
  • Video on stages of kidney disease was also shown
  • Pathophysiology of management was discussed. Management involving lifestyle modification, dietary changes, drugs, and renal replacement therapy was explained. A brief note on conservative therapy was discussed for patients who do not want to opt for renal replacement therapy.


After the session, students' feedback was taken by a questionnaire [Table 1].[10] The questionnaire consisted of students' perception and feedback on ECE sessions.
Table 1: Studentsf feedback (on 5.point Likert Scale serial number 1 to serial number 10) with statistical analysis

Click here to view


Statistical analysis

Microsoft office Excel 2007 and SPSS version 21.0. (Armonk, NY, USA: IBM corporation) were used for data entry and analysis. Student's perception of ECE was recorded by taking feedback on ten closed ended items on five-point Likert scale and two open-ended questions (n = 68). Internal consistency of the questionnaire was assessed by Cronbach's alpha (value = 0.872); closed ended questions were analyzed by the options chosen and with percentages whereas open-ended questions were analyzed by screening and extracting themes.


  Observations and Results Top


The feedback of participating students was taken by a questionnaire on ten items on five-point Likert scale after the second session of ECE. These 5 points were: 1 = Strongly disagree, 2 = Disagree, 3 = Neither agree nor disagree, 4 = Agree, and 5 = Strongly agree. The questionnaire consisted of ten close-ended questions and two open-ended questions [Table 1].

Majority students (89.67%; strongly agree 35.28% and agree 54.39%) commented that ECE was more interesting method of teaching learning compared to traditional lecture. Many (77.94%; strongly agree 26.46% and agree 51.45%) opined that ECE increased their attention in class. When asked whether ECE will motivate them to read more about the topic, majority (75%; strongly agree 17.64% and agree 57.33%) of responses were in affirmation. Most of the students (80.85%; strongly agree 22.05% and agree 58.80%) felt that ECE helped them to understand the topic better and also helped them (83.82%; strongly agree 29.4% and agree 54.39%) in better retention of topic. More than half the (88.23%; strongly agree 32.34% and agree 55.86%) students opined that ECE helps in correlating physiology to clinical cases and in turn helped them (89.70%; strongly agree 42.63% agree 47.04%) in realizing the importance of studying physiology. Greater number of students (92.64%; strongly agree 39.69% and agree 52.92%) also felt that ECE method should be introduced in teaching other topics and other basic science discipline (88.23%; strongly agree 39.69% and agree 48.51%). When asked whether ECE should be incorporated in curriculum for future batches, most of them (88.23%; strongly agree 51.45% and agree 36.75%) answered in affirmation.

While analyzing open-ended questions, some interesting themes emerged. Students felt that ECE is definitely interesting (47.1%), helps to build concepts (26.5%), helps in retention of topic (36.8%), is interactive (26.5%), and helps to correlate physiology to clinical (51.5%). When asked for suggestions in improving ECE, students (50%) opined that they would like to have a direct interaction with patients (hospital visits), more sessions (32.3%), and more videos (11.8%).


  Discussion Top


Our study results suggest that ECE is an interesting, interactive form of teaching. It helps build concepts and helps correlate physiology to clinical sciences, and it should be made a part of curriculum.

The medical students have to learn basic sciences for 1 year before they begin interacting with patients. The main challenges pertaining to this undergraduate curriculum are to make physiology interesting for the students as well as to make them understand the importance of the subject. Different computer-assisted modules have been tried to overcome these challenges, but their feasibility is limited.[11] ECE helps in teaching physiology in clinical context, helps to build concepts, and emphasizes the importance of studying basic sciences.[12]

A number of studies have been undertaken to explore the efficacy of ECE.[7],[13] Their findings are corroborative with respect to students' satisfaction and acceptance of ECE. We also found a very positive response from students in our study toward ECE. ECE helps to develop clinical reasoning skills and promotes factual learning. In our study, there was no direct patient contact, but case studies were discussed along with videos. It was shown in one previous study that video graphic demonstration of clinical facts enhances students' understanding and retention.[14]

Because of time constrains, only two systems were chosen for ECE sessions. As suggested by students, ECE should be made part of other systems. Because of logistic difficulty involved, there was no actual patient contact. Fifty percent of students were in favor of actual patient contact. These could be considered as limitations of the study. The questionnaire was not prevalidated – another limitation of the study.


  Conclusion Top


Two ECE sessions were introduced to 1st year MBBS students. Medical students received it positively. ECE is an effective method to supplement the traditional teaching. It is practically oriented and interactive and helps build concepts. MCI is introducing ECE in the new curriculum to be implemented from admission batch 2019.[15] ECE will help bridge the gap between preclinical and clinical subjects and make learning more interesting.

ECE would enhance the logical reasoning skills of the students. They would learn to think scientifically instead of studying by rote learning. This pattern of teaching will also help students to retain the material for longer duration and would help them make the horizontal and vertical integration as they proceed through the undergraduate studies. Development of analytical mind will help them stand in good stead as they go through their professional lives.

Acknowledgments

We are grateful to Dr. Tejinder Singh, Dr. Dinesh Badyal and all the faculty of ACME at CMCL Nodal center for their guidance and support.

Our sincere thanks to Dr. Rajneesh Calton, Professor and Head Department of Cardiology, CMCL and Dr. Timothy Rajamanickam Professor and Head Department of Nephrology, CMCL for sharing cases for ECE sessions.

We are grateful to students of 1st year MBBS, CMCL for participating in the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Medical Council of India. Regulations on Graduate Medical Education 1997. Available from: http://www.mciindia.org/know/rules/rules_mbbs.htm. [Last accessed on 2018 Aug 03].  Back to cited text no. 1
    
2.
MCIBooklet: Vision; 2015. Available from: https://old.mciindia.org/tools/announcement/MCI_booklet.pdf. [Last accessed on 2018 Aug 03].  Back to cited text no. 2
    
3.
Malau-Aduli BS, Lee AY, Cooling N, Catchpole M, Jose M, Turner R. Retention of knowledge and perceived relevance of basic sciences in an integrated case-based learning (CBL) curriculum. BMC Med Educ 2013;13:139.  Back to cited text no. 3
    
4.
Ramachandran K, Chacko TV, Grant J, Bhandary S. Early clinical exposure through innovative interactive clinical anatomy lectures. Natl Med J India 2015;28:291-4.  Back to cited text no. 4
    
5.
McLean M. Sometimes we do get it right! Early clinical contact is a rewarding experience. Educ Health (Abingdon) 2004;17:42-52.  Back to cited text no. 5
    
6.
Khabaz Mafinejad M, Mirzazadeh A, Peiman S, Khajavirad N, Mirabdolhagh Hazaveh M, Edalatifard M, et al. Medical students' attitudes towards early clinical exposure in Iran. Int J Med Educ 2016;7:195-9.  Back to cited text no. 6
    
7.
Sathishkumar S, Thomas N, Tharion E, Neelakantan N, Vyas R. Attitude of medical students towards early clinical exposure in learning endocrine physiology. BMC Med Educ 2007;7:30.  Back to cited text no. 7
    
8.
Das P, Biswas S, Singh R, Mukherjee S, Ghoshal S, Pramanik D. Effectiveness of early clinical exposure in learning respiratory physiology among the newly entrant MBBS students. J Adv Med Educ Prof 2017;5:6-10.  Back to cited text no. 8
    
9.
Singh T, Gupta P, Singh D. Integrated teaching. In: Gupta P, editor. Principles of Medical Education. 4th ed. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2013. p. 24-5.  Back to cited text no. 9
    
10.
Rawekar A, Jagzape A, Srivastava T, Gotarkar S. Skill learning through early clinical exposure: An experience of Indian medical school. J Clin Diagn Res 2016;10:JC01-4.  Back to cited text no. 10
    
11.
Mukherjee S, Mukhopadhyay D, Das P. Usefulness of animal simulator software in teaching amphibian physiology practical for 1st prof MBBS students. J Contemp Med Edu 2016;4:21-4.  Back to cited text no. 11
    
12.
Prithishkumar IJ, Holla SJ. Early clinical exposure as a teaching learning tool to teach neuroanatomy for first year occupational and physical therapy students – Our preliminary experience. Indian J Physither Occup Ther Int J 2012;6:59-62.  Back to cited text no. 12
    
13.
Ebrahimi S, Kojuri J, Esfahani SA. Early clinical experience: A way for preparing students for clinical setting. GMJ 2012;1:42-5.  Back to cited text no. 13
    
14.
Shridevi AS, Gayatri LP, Arif NK, Rashmi AG, Shashikala P. Role of audio visual aid as a teaching - Learning method for understanding mechanism of labour. J Pub Health Med Res 2013;1:97-9.  Back to cited text no. 14
    
15.
Mci UG. Curriculum. Vol. 1. Available from: https://www.mciindia.org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-I.pdf. [Last assessed on 2019 Aug 28].  Back to cited text no. 15
    



 
 
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