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Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 301-306

Early clinical exposure on Gout for first year medical undergraduates at a tertiary care teaching hospital in South India- A mixed methods study

1 Department of Biochemistry, NRI Medical College, Guntur, Andhra Pradesh, India
2 Department of Orthopedics, NRI Medical College, Guntur, Andhra Pradesh, India

Date of Submission10-Mar-2022
Date of Decision19-Mar-2022
Date of Acceptance21-Mar-2022
Date of Web Publication17-Mar-2023

Correspondence Address:
Dr. Vijayalakshmi Udipi Badikillaya
Department of Biochemistry, NRI Medical College, Guntur - 522 503, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrntruhs.jdrntruhs_49_22

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Background: The department of biochemistry at a tertiary care teaching hospital had the first offline early clinical exposure (ECE) on gout in October 2021 in the aftermath of COVID 19. This paper is based on our experiences of conducting ECE according to Competency Based Medical Education in the classroom.
Aim: To share our experiences of conducting ECE in a faculty constrained setting.
Methods: This was a mixed methods study. A total of 187 students out of 200 were present on the day of ECE. A pre- and post-test of ten questions on nucleotide metabolism was administered to the students. The subject for the module was a 48-year-old farmer suffering from gout who kindly consented to be a part of the program which was coordinated with the orthopedics department. After the module, the students wrote their reflections in the logbook and also gave their written feedback.
Results: The reflections revealed that they felt motivated to study the biochemical aspects of the disease as this helped them understand the clinical picture. The feedback revealed that they preferred having more such ECE sessions. The mean post-test and pre-test scores were 7.7 and 5.6, respectively.
Conclusion: ECE improved the students' learning and motivated them to study the subject. The reflection and feedback by students demonstrate that the students were enthusiastic and motivated to participate in the ECE. The objective in disseminating our findings is to share the ECE experiences so that we can standardize the competencies and objectives of common clinical conditions in biochemistry.

Keywords: CBME, feedback, purine catabolism, reflection

How to cite this article:
Harika K, Badikillaya VU, Vuddandi S, Hukumathirao KK, Jammalamadaka P. Early clinical exposure on Gout for first year medical undergraduates at a tertiary care teaching hospital in South India- A mixed methods study. J NTR Univ Health Sci 2022;11:301-6

How to cite this URL:
Harika K, Badikillaya VU, Vuddandi S, Hukumathirao KK, Jammalamadaka P. Early clinical exposure on Gout for first year medical undergraduates at a tertiary care teaching hospital in South India- A mixed methods study. J NTR Univ Health Sci [serial online] 2022 [cited 2023 Mar 21];11:301-6. Available from: https://www.jdrntruhs.org/text.asp?2022/11/4/301/371761

  Introduction Top

A much needed overhaul of the medical curriculum in India was done by the National Medical Commission – NMC (erstwhile Medical Council of India – MCI). We now have an outcome-based or competency-driven curriculum. The goal of the NMC is to prepare the Indian Medical Graduate (IMG) to become a physician of first contact or a primary care physician. To aid in this goal it has listed out five roles for the IMG which are; a clinician, leader, communicator, lifelong learner, and professional. It has also spelt out the competencies to be attained to reach that goal.[1]

One of the changes in the curriculum is early clinical exposure (ECE), which introduces the first-year medical undergraduates to a few aspects of clinical and social context in patient care. The purpose is to provide a link between basic sciences and clinics. The elements of ECE according to the guidelines provided by the NMC are (a) provision of clinical correlation to basic science learning (b) providing authentic human contact in a social or clinical context that enhances learning in the nascent years of a medical undergraduate and (c) introducing humanities in medicine.[1]

Such an early exposure with the major stakeholder, that is, the patient; in the students' life helps in experiential learning, and motivates the student to integrate the concepts and observe their application in patient care. It was found that ECE improved the students' clinical skills, communication skills, empathy, and altruism.[2],[3] It helps in the smooth transition of the student from a layperson to a student doctor, encourages the student to learn professional behavior, and provides training in basic clinical skills. It provides an opportunity to make the basic sciences clinically relevant and provides the social context of the patient.[4] The students exposed to ECE in India were appreciative and felt that it enhanced their learning.[5],[6] The faculty perception was that ECE increases learning of students, provided better comprehension of basic science knowledge.[7],[8] Senthil et al.[9] in their review on ECE bemoaned the fact that implementing this program in medical colleges in India becomes challenging due to inadequate number of faculty members and the large student numbers ranging from 150 to 250. Conducting ECE in the hospital setting becomes very resource intensive due to this. The NMC has stated that the students should be provided with an observation guide, so that it helps them to appreciate what they have observed and will direct their attention to the learning objectives. Shah has stated that identifying clinically relevant core content and framing learning objectives is also a challenge for faculty, as they have to be trained. The roles that the student can play in the ECE session are: being a passive observer, an active observer, an actor in rehearsal or an actor in performance. Being a passive observer is just observing the happenings. An active observer is when the student is involved, as in recording the findings. An actor in rehearsal is when the student practices on a simulator and an actor in performance is when the student assists the resident in performance of a task.[10]

The present study was conducted at a tertiary care teaching hospital in India which has a Phase I student intake of 200. Through this study, we wish to share the academic performance and experiences of medical students following the ECE module.

  Aims and Objectives Top

  1. To determine the effectiveness of ECE in improving the academic performance of students.
  2. To share our experiences of conducting ECE according to competency based medical education (CBME) in a resource constrained medical college with modifications in ECE to suit our needs.

  Methods Top

Study design

It was a cross-sectional observational study with a mixed methods study design.

Study setting

The ECE was conducted at a tertiary care teaching hospital in South India by the Department of Biochemistry on Gout in October 2021. The setting was the Lecture Gallery.

Selection of participants

All the 187 first-year MBBS students who were present on the day of ECE. The students were informed after the ECE that a study would be done on the present ECE module and that their data that included reflections, feedback, and test scores would be used for the study only if they gave their consent. They were also assured that those who did not wish to share their data would be treated no differently by the faculty. They were told that the results would be shared with them. All the students consented to participate in the study.

Informed consent was taken from the students and also from the patient. The institutional ethical approval was taken [IEC NRIMC 371].


Clinical encounter with a patient having gouty arthritis. The relevant competencies for the ECE on gout were identified [Table 1]; and accordingly six objectives were prepared which were:
Table 1: Competencies for the Module

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  1. Describe the purine catabolic pathway.
  2. Enumerate the causes of primary and secondary hyperuricemia.
  3. Explain the cause of gouty arthritis in peripheral areas of the body.
  4. Explain the biochemical basis of tests ordered.
  5. Explain the biochemical basis of treatment.
  6. Explain the role of triggering factors in causing hyperuricemia.

An observation guide was prepared by the faculty so that when the clinical interview was conducted, the student would note down the relevant points of the clinical encounter in their logbooks [Table 2]. This will involve the student in the ECE as he now becomes an active observer.
Table 2: Relevant Points of the Clinical Encounter

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Method of measurement

A questionnaire of ten multiple choice questions (MCQ) was prepared after validating it. The pre-test questionnaire helps the student to identify his/her lacunae in the topic and also be primed to focus on the ECE more attentively. The topic of nucleotide metabolism and gout was already covered as an interactive large group lecture 2 months prior to the ECE and was spread over 3 h.

Primary outcome measures

The effectiveness of ECE in improving the academic performance of students was assessed by the questionnaire (objective measure), and reflections and feedback from students was used as a subjective measure of effectiveness.

Data analysis

The pre- and post-test scores were compared using the paired t test and the results were considered significant if P ≤ 0.05. The reflections and feedback were analyzed by content analysis. It was analyzed by the second author who has undergone training in qualitative research methodology, and also by a qualitative data analyst. Triangulation of data was done for the qualitative data by using two different analysts for the data and triangulation of methods was done using open-ended questions in the written feedback and by asking them to write their reflections, which was the qualitative data collection tool and pre and post-tests were the quantitative data collection tool. The software used was MS Excel for paired t test.

Program implementation: It was conducted over a 3 h period in the afternoon from 1.30 to 4.30 pm. [Figure 1].
Figure 1: Flow chart of the module

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The patient was a 48-year-old farmer suffering from gout who kindly consented to be part of the program which was coordinated with the Orthopedics Department. The competencies, objectives, and observation guide were shared with the Assistant Professor Orthopedics 1 week prior to the ECE. The students were briefed about the program through WhatsApp 1 week prior to the event. The students and faculty stood up, folded their hands and greeted the patient when he came in. After the patient was seated the students and faculty sat down. The program was implemented as shown in [Figure 2]. The clinical expert used PowerPoint slides and images of the patient so that the debilitating effects of gout were appreciated by all the students. The interaction with the patient by the clinical expert was duly noted by the students who focused on their communication as directed by the observation guide. The observation guide was also shared with the clinical expert so that he would ask the relevant questions in the history which the students took note of. The students questioned the clinical expert and got their doubts cleared. The students were in the role of an active observer by noting down the relevant points according to the observation guide in their logbooks. After the summary, the key points were once again reinforced by a faculty member. After this, the students thanked the patient for helping them understand the disease and the patient was bid a grateful goodbye. This was followed by a post-test.
Figure 2: Student–patient interaction in the gout module of early clinical exposure

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  Results Top

[Table 3] shows the mean and standard deviation (SD) of pre-test and post-test. There is a statistically significant difference as seen by a P value of <0.001. Reflections written by students in their logbooks and the feedback given by students were analyzed qualitatively by content analysis and themes were identified as seen in [Table 4] and [Table 5]. The themes in the reflections were metacognitive skills, interactive learning, authentic patient contact, clinical correlation, and modification in the module. The themes in the feedback were metacognitive skills, clinical correlation, and modification in module.
Table 3: Mean And SD Scores of the Students in the Pre- and Post-Tests

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Table 4: Content Analysis of the Written Feedback

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Table 5: Content Analysis of Reflections in the Logbook

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  Discussion Top

In 2019, NMC introduced Competency Based Medical Education (CBME) in India and introduced ECE as one of the compulsory practices in regular teaching.[11] The ECE conducted at our college in biochemistry created interest in the students and helped them understand the subject better as was evidenced by their post-test scores and their feedback. In any teaching–learning (T/L) method motivation is very important. Majority of the students gave the feedback that they felt motivated to study the topic during the ECE and did not want any change in the module and wanted more of such sessions included in their timetable. On content analysis the students empathized with the patient and mentioned it as one of the reasons for being motivated to study. These findings are in accordance with the study conducted by Chari et al. and Baheti et al.[12],[13] They reported that students were positive about the ECE and had increased motivation to study the subject which correlates with the present study. Students stated in their feedback that ECE had improved their attention in the class, knowledge about the topic, and gave them motivation to read. They also felt that the authentic patient contact helped them in linking the subject with the clinical features seen in the patient. These findings are in accordance with the study of Rawekar et al.[14] which also reported students giving a positive feedback about ECE. In the present study, students reported that ECE helped them in understanding the relevance of biochemistry in a clinical setting and it should be used as a method of T/L along with regular classes in biochemistry as well as other basic subjects in the first professional MBBS curriculum, a finding consistent with a study done by Kumar et al.[15] Four students suggested some changes that could be made in the module like increasing the duration of interaction with the patient and that a hospital setting would have felt more authentic. They also mentioned that inclusion of case-related videos would have made the ECE effective. This finding is similar to the feedback given by students in a study conducted by Govindarajan et al.[16]

The reflections followed the pattern of; “what happened? So what and what next?” Most of the students said that they could link the concept learnt in the biochemistry topic with the clinical condition and saw the relevance of investigations and the treatment given. The reflection also helped them to identify their knowledge gaps and motivated them to study further. Students belonging to first-year MBBS at a medical college in Coimbatore in Tamilnadu also experienced increased motivation after the ECE and said that they acquired the psychomotor skills and could correlate the theory behind the application of knowledge.[16] The authors of the study Govindarajan et al.[16] conducted the ECE by involving several departments like Radiology, Nephrology, Cardiology, Neurology, and the skills lab. They allotted 1 h at the end of the day for ECE. They divided 150 students into teams comprising of 10 students. In this way the students were exposed to the hospital setting for 10 h overall. There was improvement in the post-test scores in these students, who reported that they wanted more such sessions. This was very similar to our study and the content analysis of open-ended questions revealed similar statements by the students. They too adopted a novel method of conducting the ECE involving several departments.

In our study, we prepared an observation guide for the ECE session in the classroom setting that was shared with all the students. This was the modification that we made so that all the students are actively engaged with the ECE experience.

Our study has prepared competencies and objectives for the given ECE session along with observation guide in the classroom setting, which helped the students in clearly identifying the objectives to be achieved and will help other researchers in this area to replicate a similar ECE module. A content analysis was done on the feedback and reflections were provided by the students. The study was based on ECE conducted at a single medical college on a single batch of students. We cannot generalize the experience. Also no comparison group was used. The present study has observed that ECE improved the students' learning and motivated them to study the subject. The reflection and feedback by students demonstrates that students were enthusiastic and motivated to participate in the ECE. The objective in disseminating our findings is to share the ECE experiences so that we can standardize the competencies and objectives of common clinical conditions in biochemistry.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Medical Council of India. Early Clinical Exposure for the Undergraduate Medical Education Training Program. 2019. pp. 1-43.  Back to cited text no. 1
Ogur B, Hirsh D, Krupat E, Bor D. The Harvard medical schoolcambridge integrated clerkship: An innovative model of clinical education. Acad Med 2007;82:397404.  Back to cited text no. 2
Tayade MC, Latti RG. Perception of medical faculties towards early clinical exposure and MCI Vision 2015 documents in Western Maharashtra. J Clin Diagn Res 2015;9:CC124.  Back to cited text no. 3
McLean M. Sometimes we do get it right! early clinical contact is a rewarding experience. Educ Health 2004;17:42-52.  Back to cited text no. 4
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Sathish KS, Thomas N, Tharion E, Neelkantan N, Vyas R. Attitude of medical students towards Early Clinical Exposure in learning endocrine physiology. BMC Med Edu 2007;7:30.  Back to cited text no. 5
Satheesha N, Komattil R, Nagabhooshana S, Kuvady LB. Teaching anatomy in a problem –based learning (PBL) curriculum. Neuroanatomy 2006;5:2-3.  Back to cited text no. 6
Miglani AK, Arora R. Introduction of early clinical exposure (ECE) in 1st year M.B.B.S students in the department of physiology. Int J Physiol 2020;8:9-14.  Back to cited text no. 7
Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: Systematic review. BMJ 2005;331:387-91.  Back to cited text no. 8
Velou S, Ahila E. Expectations and challenges of early clinical exposure programme for first year medical students in India. IAIM 2020;7:59-65.  Back to cited text no. 9
Shah C. Early clinical exposure- Why and how. J Educ Technol Health Sci 2018;5:2-7.  Back to cited text no. 10
Sharma R, Bakshi H, Kumar P. Competency-based undergraduate curriculum: A critical view. Indian J Community Med 2019;44:77-80.  Back to cited text no. 11
[PUBMED]  [Full text]  
Chari S, Gupta M, Gade S. The early clinical exposure experience motivates first year MBBS students: A study. Int J Edu Sci 2015;8:403-5.  Back to cited text no. 12
Baheti SN, Maheshgauri D. Early clinical microexposure (Ecmix) (A path from early clinical micro exposure to early clinical macro exposure (Ecmax). Glob J Res Anl 2015;4:1-2.  Back to cited text no. 13
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. 14
Kumar SS, Thomas N, Tharion E, Neelakantan N, Vyas R. Attitude of medical students towards early clinical exposure in learning endocrine physiology. BMC Med Edu 2007;7:30.  Back to cited text no. 15
Govindarajan S, Vasanth G, Kumar PA, Priyadarshini C, Radhakrishnan SS, Kanagaraj V, et al. Impact of a comprehensive early clinical exposure program for preclinical year medical students. Health Prof Educ 2018;4:133-8.  Back to cited text no. 16


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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