Early Clinical Exposure: Concerns and Challenges: Dr Munira A Hirkani

Early Clinical Exposure (ECE) is a teaching-learning methodology, which fosters exposure of medical students to patients as early as in the first year of medical college. The goals of ECE are to provide social relevance and a context for application of the basic science teaching. The outcomes are: gain in medical knowledge, achieving few basic clinical skills, and internalizing a wide range of attitudes.

The learning experiences offered in the preclinical phase play an important role in laying a strong foundation for learning clinical subjects. The objectives of the preclinical phase are not only to cater to the framed subject-wise outcomes, but also to keep the students motivated and make learning relevant to patient care. Patient interaction in supervised settings will facilitate students to learn from patients in a holistic manner. Students will get an opportunity to understand disease as perceived by patients and its financial, social, physical and psychological impact on them. Early involvement in the healthcare environment also validates students’ decision to opt for medicine as a career.

There have been a few concerns expressed by faculty regarding the concept, implementation and assessment of ECE. We are addressing a few of these concerns in a pointwise fashion here:

  • Students are already burdened with the curriculum of subjects of Phase 1. Now with the additional load of clinical teaching, less time and importance will be devoted to the basic science subjects. “If a student is forced to learn clinical topics as part of core competencies he will forget the basic mechanisms that are actually core of the subject”.

Early clinical exposure is a teaching-learning strategy that involves introduction of clinical content to enhance the relevance and understanding of the basic science subjects. It is not meant for learning of the diagnosis and disease management, but rather understanding how the altered anatomy, physiology and biochemistry lead to the various manifestations of the disease. Students motivated as a result of these experiences would be more likely to learn with a deeper approach and adopt self- directed learning strategies to achieve their learning targets.

EXAMPLE: Observation of a patient of chronic obstructive pulmonary disease (COPD) during ECE should be followed up with discussion on understanding the reason of slow deep breaths, so that the concept of airway resistance, lung compliance and work of breathing are reinforced. So, to conclude, ECE involves teaching the basic science concepts planned around the clinical content/ case and not teaching the clinical content. If a student understands the basic mechanism and regulations and its importance, he will appreciate the importance of the subjects learnt in preclinical phase.

  • When planning the ECE sessions which domain of learning should be addressed?

ECE supplements and enriches the regular teaching and learning of various concepts and clinical skills. ECE should be used, but not limited to achieving the higher learning objectives in the cognitive domain. It will be an excellent tool to develop the attitude of professionalism and effective communication skills. During the first-year clinical exposure should be ideally limited to observation of the doctor-patient interaction and demonstration of some important clinical signs.

EXAMPLE: The objectives of exposing the students to a patient of anemia should be to explain the derangement of functions due to decreased haemoglobin count and the altered hematological investigations expected, along with demonstration of pallor. The objectives however should be extended to include the realization of the social and financial impact of the disease and its treatment.

  • Which phase faculty will be responsible to conduct ECE sessions?

ECE is an activity which will require teamwork. The preclinical faculty will be able to decide best, the topics for ECE, frame its objectives and schedule it in their programme. Keeping in mind the purpose of ECE as envisaged by the Medical Council of India (MCI), the preclinical faculty would be the best to conduct these sessions and facilitate the discussion. However, participation of the clinical faculty, although not a must would not be amiss depending on the type of sessions planned.

EXAMPLE: Visit planned to the Blood bank or dialysis unit can be conducted by the faculty involved with the working of these units on a day-to-day basis. ECE sessions for anemia, jaundice, hypertension or diabetes mellitus in OPDs or wards, can be conducted by preclinical faculty themselves.

It always helps to collaborate and discuss with faculty of other phases during planning, and partner with them for the smooth implementation of the sessions. ECE sessions planned in community settings, e.g. for malnutrition, will require greater support of Community Medicine specialists for its planning, implementation and conduct.

  • It will be so difficult to organise the ECE sessions for the 100 or more students to the Hospitals. The same patient may not be available the next time an ECE session is planned. The number of faculty are also insufficient. How can we manage?

The large number of students in many of the colleges at present does pose a challenge to the conduct of ECE. But the large number of clinical cases available at most hospitals will provide the solution and so will judicious use of technology. What can be done is that some ECE sessions can be planned in the classroom settings, to help correlate basic science subjects. Videos of real or simulated patients, report of laboratory investigations, photographs and other relevant clinical material can be used.

EXAMPLE: For endocrine disorders like gigantism, acromegaly, hyperthyroidism etc. the doctor-patient interaction can be video recorded with permission for teaching purpose. These videos will ensure that all students are exposed to similar content and will also make the sessions more manageable in terms of faculty requirement. Though it is still advisable to discuss in smaller groups to maintain interactivity.

The ECE conducted in the classroom seems to be the least resource-intensive and feasible, but bringing them into the authentic hospital environment will go a long way to inculcate attitudes and motivate students.

It may not be possible or necessary to have the same patient for all the students undergoing ECE sessions in the hospital setting. Planning these sessions on similar cases to achieve the objectives will do the trick.  

EXAMPLE: For ECE to hemiplegia or Parkinson’s disease, even if different patients are examined by different batches of students, the objectives (e.g. to discuss the impact of the locomotor disability on their life, its financial implication and providing explanation of basis of symptoms and signs) can still be achieved.

  • How to assess the objectives of Early Clinical Exposure?

Formative assessment plays an important role in the assessment of ECE. Reflections written down by the students and reviewed by the faculty will help assess the objectives of ECE planned. The attitudes, the learnings (both knowledge and skills) can be documented in the log book. A record of students’ participation in various activities and discussion during ECE should be maintained.

Summative assessment can include modified essay questions, clinical vignette-based short answer questions requiring students to demonstrate understanding of alteration in normal anatomy, physiology and biochemistry and its clinical expression.

EXAMPLE: A healthy male aged 45 years, visits an ophthalmologist complaining of double vision since last three months along with drooping of eyes. The symptoms are more pronounced in the evening. He has no other associated symptoms and is not taking any other treatment. His physical, neurological and ophthalmic examination are normal. On blood investigations, acetylcholine receptor antibodies are detected.

  • Explain the altered physiology leading to the above condition.

“Many ideas grow better when transplanted into another mind than the one where they sprang up.” So keep sharing best practices with each other.

(Dr Munira A Hirkani is an Associate Professor in the Dept. of Physiology, at Seth GS Medical College & KEM Hospital, Mumbai. She is Associate Director of the GSMC FAIMER Regional Institute, Mumbai and Co-Convener MCI Nodal Center. )

Simulation-based learning in competency-based medical education: The Indian context: Dr Dinesh Badyal

Simulations are being used in the airline industry for training, re-training and certification. For the airline industry, safety is of paramount importance. Medical services also look at safety as a very important parameter. Risk reduction strategies are being used in these two areas. Medical education curricula have been trying to use simulation-based learning (SBL) for years. Simulations are presently being used for skill acquisition and assessment. However, the following dilemmas remain: what to use in simulations, why to use simulations and how to use simulations for learning.

In India, we have two contrasting scenarios related to availability of clinical material for learning in medical colleges. In some well-established colleges there are large number of patients, while in other colleges, there are a smaller number of patients or patients refuse examination by students. Simulations and simulation-based teaching can be useful in these scenarios. The use of skills and simulation labs have become mandatory in India for undergraduate medical education from 2019 as per the new competency-based curriculum.

Due to the above reasons, medical colleges are trying to set up simulation labs and start simulation-based teaching. However, unfortunately most colleges buy mannikins and fill their simulation labs with a variety of plastic material without realizing their need or without having any teaching-learning relevance. In a way they invest heavily in plastic mannikins but not in training their stakeholders in how to develop and implement simulation-based teaching-learning.

Simulation laboratories can be used to learn technical or non-technical skills. Non-technical skills including communication, team-based learning etc. can be very effectively taught in simulated scenarios. In technical skills, techniques like intravenous injections, lumbar puncture can be done repeatedly and improvements can be done. It is not always possible to learn these skills in real encounters. Therefore, simulation encounters using various simulations e.g. mannikins, standardised patients, or hybrid models can help a lot to improve student learning and patient safety. The confidence of learners improve and they can practice multiple times on simulations and also take remedial actions. Otherwise, a learner cannot poke a patient multiple times to learn intramuscular injections.

The development of low-resource intensive simulations and simulated  environments can contribute to better skills learning and improved patient safety. It is reported to improve patient outcomes too. The use of low-fidelity simulation can be also very useful if appropriate teaching learning methods are employed. The educational material in a simulation module can include learning objectives, methods, material needed, logistics  about space, time, practice time, faculty training tips and assessment strategies e.g. checklists, OSAT (Objective structured assessment of technical skills), OSCE (Objective structured clinical examination), OSPE (Objective structured practical examination). The possibility of using hybrids i.e. video/computer simulation/ real patients should be explored as in India at number of places ample number of patients are available. Hybrid models can be used for intramuscular injection by using actual subject for palpation of bony landmarks and marking site of injection followed by actual administration into simulated arm.

All stakeholders should make appropriate efforts and invest time & money in equipping faculty with skills to develop educational material for the simulation-based learning and train more and more faculty in using simulations in learning.

(Dr Dinesh Badyal is Professor, Dept of Pharmacology & Professor, Dept of Medical Education, Christian Medical College, Ludhiana. He is a FAIMER Institute Fellow, an IFME Fellow, and a CMCL-FAIMER Fellow. He is Director of the CMCL-FAIMER Regional Institute and Convener, MCI Nodal Centre for Faculty Development.)