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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 3  |  Page : 97-100

The effectiveness of early clinical exposure in teaching anatomy: A study among 1st year medical students

1 Associate Professor, Department of Anatomy, D.Y. Patil Medical College, Kolhapur, Maharashtra, India
2 Professor and HOD, Department of Anatomy, D.Y. Patil Medical College, Kolhapur, Maharashtra, India
3 Professor, Department of Surgery, D.Y. Patil Medical College, Kolhapur, Maharashtra, India
4 Tutor, Department of Anatomy, D.Y. Patil Medical College, Kolhapur, Maharashtra, India

Date of Submission18-Jun-2020
Date of Decision10-Jul-2020
Date of Acceptance23-Sep-2020
Date of Web Publication15-Oct-2020

Correspondence Address:
Anita R Gune
Associate Professor, Department of Anatomy, D.Y. Patil Medical College, Kolhapur, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/NJCA.NJCA_31_20

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Background and Objective: The new study model of the Medical Council of India 2015, suggested the introduction of a module of early clinical exposure (ECE) to 1st year medical students to improve their understanding of the subjects taught. Thus, the main objective of the study was to assess; how students respond to the modified curriculum of ECE in the 1st year. Methodology: Cross-sectional study was conducted among 1st year medical students (n = 140) and were brought to the hospital; followed by the demonstration of a visual relay of an appendectomy procedure, which in turn was followed by an interactive session with the facilitators. Following this, the students filled a questionnaire (designed as per the Likert scale) about their opinion of the module. In addition, a test was conducted before and after the module to assess the comprehension of the subject by the students. Statistical analysis was performed using descriptive statistics (for qualitative variables) and t-test, for determining the significance between pre- and post-test scores. Results: Ninety-five percent of the students responded extremely well to ECE and was appreciated by the students. This was clear through the positive feedback received on improvement in understanding and interest in the subject. The pre- and post-test evaluation also resulted in a significant increase in test scores, (P = 2.20e−16). Conclusion: ECE module significantly helped 1st year medical students to comprehend the topic better. It made learning interesting and helped those correlate basic sciences with their clinical applications and relevance in practical medicine.

Keywords: Appendectomy, comprehension, learning, medical students

How to cite this article:
Gune AR, Nikam VR, Gaikwad VV, Wagh DT. The effectiveness of early clinical exposure in teaching anatomy: A study among 1st year medical students. Natl J Clin Anat 2020;9:97-100

How to cite this URL:
Gune AR, Nikam VR, Gaikwad VV, Wagh DT. The effectiveness of early clinical exposure in teaching anatomy: A study among 1st year medical students. Natl J Clin Anat [serial online] 2020 [cited 2021 Jun 13];9:97-100. Available from: http://www.njca.info/text.asp?2020/9/3/97/298162

  Introduction Top

Gross human anatomy is among the oldest branches of medicine which sets the foundation for medical education and knowledge.[1] It is a significant subject, fundamental for medical education, since its understanding is of utmost importance in good clinical practice and is believed to lay the foundation for expertise in surgery.[2] Currently in India, applied anatomy is a part of the curriculum of 1st year medical education. However, conventional classroom education imparts a feeling of endless gathering of facts without clinical activity leading to a sense of disenchantment among them. The initial years of medical education are vital for academic success. In the conventional medical school teaching pattern, students are taught theory in compartments of subjects while true clinical exposure occurs only in the final year. The traditional curriculum during the early years of medical education may make them thorough in biomedical sciences but sparingly contributes towards skills for clinical experience. Conventionally, teaching of gross anatomy is delivered through cadaver dissections and didactic lectures.[3]

Establishing a strong association between preclinical didactics and its relevance to clinical practice, early on is required for the students. It helps in recognizing the practical relevance of the curriculum during their preclinical anatomy courses and to transfer knowledge more efficiently.[4] Thus, early clinical exposure (ECE) is thought to act as a bridge between preclinical and clinical disciplines. Education systems across the world now emphasize early ECE towards horizontal and vertical integration and contextual learning. In line with its implications, the Medical council of India, New Delhi, recommended ECE in the newly proposed syllabus from 2015.[5] ECE is a teaching learning methodology, which fosters exposure of the medical students to the patients as early as the 1st year of medical school.[6],[7] Integrated learning courses, like ECE, are courses wherein knowledge and skills from across disciplines are utilized to address patient cases to create problem-based learning experiences for students. Integration of the knowledge of basic science with clinical science through ECE can contribute to better understanding of the relevance of the basic course on anatomy. It provides an opportunity for students to actively interact and learn from patients and clinicians. By introducing the students to basic clinical skills, professionalism, and student-patient relation, it also enables a smooth transition into clinical training.[8]

Feedback of students is useful in identifying and improving the medical education process. Through feedback, areas of strength and weakness in the teaching methodology can be identified. In the recent years, more emphasis is being laid on student centered, integrated, and problem-based clinically relevant teaching and learning. Research has shown that ECE has helped medical students in better visualization of concepts and recollection of facts when compared to conventional classroom-based teaching.[3],[9]

This study aimed to evaluate the perception of 1st year students of medicine toward ECE as a part of the modified curriculum. As patients with appendicitis are common and as anatomy of the appendix comprises of an important part of the 1st year syllabus of Anatomy, appendectomy was chosen for ECE. It was done through the demonstration and visualization of appendectomy to students, combined with a pre- and post-demonstration test, followed by a feedback in the form of a questionnaire. The study was intended to understand how students respond to the modified curriculum of ECE in the 1st year and would they find it contributory to their learning.

  Methodology Top

The cross-sectional study was conducted among 1st year students at Dr. D. Y. Patil Medical College, Kolhapur, and Maharashtra, India in a collaborative effort by the departments of surgery. Ethical clearance was obtained from the institutional ethical committee to carry out the study. It comprised of a total of 144 students, all students were informed regarding procedure later students' willingness was obtained as written consent. They were taught about the appendix in a small group teaching setting in classroom, 5 days before the ECE. A pretest, containing questions based on the theory class, questions on surgical anatomy developed after discussions with faculty members and validated by experts in the field., was conducted among students, just before the ECE. Following this, there was a direct visual relay of laparoscopic appendectomy, which lasted for 45 min. History, signs and symptoms, indication of appendicitis and the steps of the procedure were explained by a faculty followed by an interactive open discussion. After this, a posttest was conducted on the same day, after the ECE. All the students who participated in the ECE filled a feedback form in order to assess the effectiveness of the module. The feedback on the questionnaire was based on a five-point Likert scale.[10]

Statistical analysis

Data analysis, descriptive statistics was performed using MS-Excel 365. The difference between pre- and post-test scores and levels of significance were calculated using R studio 1.2.5001.

  Results Top

In the ECE module, the students underwent a pretest followed by clinical exposure and then a post-ECE test related to the subject taught (appendectomy). Average test scores increased significantly by 2.02 ± 1.15 in comparison to pre-ECE scores, (P = 2.20e −16) as depicted in [Table 1] and [Figure 1]. Thus, we found that there was much improvement in the understanding and learning outcomes in the students.
Table 1: Pre- and post-early clinical exposure test scores among 1st year MBBS students are represented

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Figure 1: Graph comparing pretest and posttest P-value

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The students were asked to fill a questionnaire about their perception of ECE. The distribution of responses towards the questionnaire returned interesting opinions from the students. The feedback on ECE of the 144 students was analyzed and results indicated an overall positive impact on students, as presented in [Table 2]. An overwhelming 96% of tutees agreed that this method, used for teaching anatomy, made the learning process more enjoyable and developed in them, a deeper interest in anatomy. Likewise, 98% of them also agreed that they were more attentive throughout the class during the ECE session. Furthermore, 90% of the students were very excited during the actual visit to the hospital and agreed that ECE to appendectomy helped them in diversifying their thinking. In addition to the benefits provided by ECE in facilitating the learning of applied anatomy, students also felt that this module would help them feel more confident in clinical practice. Most of the students wished to experience more topics taught in this manner. For each of the questions, the number of students who did not like any aspect of this module of ECE was <10%, thereby suggesting that ECE had a very productive and positive influence on 1st year medical students.
Table 2: Perspectives of 1st year medical students towards early clinical exposure module of teaching

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  Discussion Top

Theoretical classes alone on topics in basic medical sciences often leads to a sense of dissatisfaction among students.[11] ECE comprises of an active, experiential learning from patients with practicing clinicians, tailored to be the “beginning of a life-time of learning focused on the patient.”[12] ECE was first implemented in 1993, when “Tomorrow's Doctor” by the Medical Council of the United Kingdom suggested that clinical medicine be introduced to students early in their curriculum. It was recommended to use real clinical scenarios to make teaching more relevant and stimulating. It was also done to reinforce the vertical integration between basic medical and clinical sciences.[13] Supporting this, in 1998, a study from the World Federation of Medical Education recommended that medical education should to the best extent possible amalgamate basic and clinical disciplines with a focus on key principles and that students should interact with patients early on in their education.[14] Since then, many countries have successfully implemented this module. In Europe, ECE has been reported to be implemented in 32 of their 40 medical schools.[15] Similarly, in Indonesia, where ECE has been implemented, students exhibited reduced difficulties in their clinical exposure stage.[16] Despite its usefulness, its implementation remains a challenge in India, due to a large number of students in each class. Therefore, the assessment of the efficacy of this module on a large scale is lacking compared to developed countries. Implementation of ECE involves three types of settings: college or a classroom setting, hospital or ward setting and community setting. Fourteen students can participate in ECE modules either as active participants or passive recipients, facilitating better exposure to clinical settings for the students.

In this investigation, feedback from the students indicated that they found the ECE module enjoyable when demonstrated after theoretical teaching. When the pre- and post-ECE test scores were compared, interestingly, the students performed notably well post the ECE, in contrast to pre-ECE. This kind of module has been proven to be useful in understanding anatomy in previous studies as well and the present investigation is well in accordance with other recent studies involving ECE.[17]

Different methods of ECE have been applied in other subject areas as well. A recent study showed that specific case-based lectures, hospital visits, and periodic interactions with patients and clinicians helped students understand endocrine physiology better. As many as 96.4% students supported this type of ECE module.[18] Similar observations were made while teaching neuroanatomy to students through ECE, where the group of students when taken to the hospital and examined the patients performed better than the students who attended only conventional lectures.[12] Likewise, ECE in other subjects such as physiotherapy, physiology, nephrology, general surgery, and radiology have been shown to be a highly attractive teaching method when compared to conventional classroom teaching.[19],[20]

Overall, the ECE module which is being put into practice across various medical institutions in India is proving effective in imparting a better exposure to clinical practices to 1st year medical students. A comparative study assessing and contrasting the conventional method pitted against ECE would provide interesting insights. Studies where different ECEs are implemented across different subjects might prove useful in designing a specific and definitive course module for medical students. This would enable them to appreciate the clinical importance of the subject and employ the same in the clinical set up.

  Conclusion Top

The study demonstrated the overall positive outcomes of ECE module on the students, leading to better test scores and enhanced subject comprehension. This methodology is therefore useful in the curriculum over conventional classroom lectures. Imparting medical education through ECE would help medical students develop an interest in this field and enhance their clinical acumen. Our study was conducted and analyzed for one topic, more topics should be analyzed for better understanding of the outcome of ECE. In addition, accompanying ECE with other techniques like horizontal integration and e-learning might also help in improving the methods for studying Anatomy.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Louw G, Eizenberg N, Carmichael SW. The place of anatomy in medical education: AMEE guide no 41. Med Teach 2009;31:373-86.  Back to cited text no. 1
Harden RM, Laidlaw JM. Essential Skills for a Medical Teacher: An Introduction to Teaching and Learning in Medicine. New York: Elsevier; 2017. Available from: https://gmcsurat.edu.in/lib/exe/fetch.php? media=circular: essential_skills_for_medical_teacher_second_edition_.pdf. [Last accessed on 2020 May 02].  Back to cited text no. 2
Bandyopadhyay R, Biswas R. Students' perception and attitude on methods of Anatomy Teaching in a Medical College of West Bengal, India. J Clin Diagn Res 2017;11:AC10-14.  Back to cited text no. 3
Quintanilha LF, Costa GN, Coutinho MR. Medical student perceptions about active methodologies in the study of physiology in medical schools in Salvador, Brazil. Adv Physiol Educ 2018;42:693-6.  Back to cited text no. 4
Medical Council of India: Vision 2015. Medical Council of India 2011; March 2011. Available from: https://www.mciindia.org/CMS/wp-content/uploads/2018/01/MCI_booklet.pdf. [Last accessed on 2020 Feb 20].  Back to cited text no. 5
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Chimmalgi M, Jose R, Kumari KC. Student satisfaction with early clinical exposure and e-learning in learning anatomy. Int J Anat Res 2017;7:3398-403.  Back to cited text no. 8
Dehghan A, Amini M, Sagheb MM, Shidmoosavi SM, Nabeiei P. Early clinical exposure program in learning renal physiology. J Adv Med Educ Prof 2017;5:172-6.  Back to cited text no. 9
Allen IE, Seaman CA. Likert scales and data analyses. Qual Prog 2007;40:64-5.  Back to cited text no. 10
Yadav PP, Chaudhary M, Patel J, Shah A, Kantharia ND. Effectiveness of integrated teaching module in pharmacology among medical undergraduates. Int J Appl Basic Med Res 2016;6:215-9.  Back to cited text no. 11
Kar M, Kar C, Roy H, Goyal P. Early clinical exposure as a learning tool to teach neuroanatomy for first year MBBS students. Int J Appl Basic Med Res 2017;7:S38-41.  Back to cited text no. 12
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World Federation for Medical Education. WFME Global Standards for Quality Improvement the 2015 Revision. 2015. Available from: http://www.imeac.org/wp-content/uploads/2017/07/06_WFME_2015.pdf.  Back to cited text no. 14
Başak O, Yaphe J, Spiegel W, Wilm S, Carelli F, Metsemakers JF. Early clinical exposure in medical curricula across Europe: An overview. Eur J Gen Pract 2009;15:4-10.  Back to cited text no. 15
Widyandana D, Majoor G, Scherpbier A. Preclinical students' experiences in early clerkships after skills training partly offered in primary health care centers: A qualitative study from Indonesia. BMC Med Educ 2012;12:35.  Back to cited text no. 16
Meshram S, Gajbe U. To study the perceptions of first year MBBS students towards early clinical exposure (ECE) in anatomy (Original Study). IOSR J Dent Med Sci 2018;17:32-5.  Back to cited text no. 17
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. 18
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 Physiother Occup Ther 2012;6:59-62.  Back to cited text no. 19
Govindarajan S, Ganesan V, Kumar PA, Priyadarshini C, Radhakrishnan SS, Kanagaraj V, et al. Impact of a comprehensive early clinical exposure program. Health Prof Educ 2018;4:133-8.  Back to cited text no. 20


  [Figure 1]

  [Table 1], [Table 2]


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