EARLY CLINICAL EXPOSURE (ECE)

Dr Sandeep Kubsad
Dept of Orthopedics
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Why do I
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learn this? boring learning to be
a doctor!

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 Early Clinical Exposure

 EarlyClinical Exposure (ECE) is a teaching learning

methodology, which fosters exposure of the medical
students to the patients as early as the first year of
medical college.

Observation during Early Clinical Exposure- an effective instructional tool or a bore Elizabeth K.
Medical Education. 2003, 37: 88-89.
ECE students can play four types of roles

1.Passive Observer: observe a complicated situation

such as performance of a trocar suprapubic cystostomy
2. Active Observer: observe a simple situation such as
performance of indwelling urethral catheterization in a
patient with urinary retention and also checklist.
3. Actor in Rehearsal: performances of indwelling
urethral catheterization in a female pelvic simulator.
4. Actor in Performance: performance the students can
assist a resident in performing an indwelling urethral
catheterization in a patient.

Passive Active Actor in Active

observer observer rehearsal performance
Need for ECE
 Preclinicalin classrooms and
laboratories
 Theoretical knowledge without
contact with patient
 Cannot recall during their clinical
postings
Pre-clinical Clinical
disciplines disciplines

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Early Clinical Exposure (ECE)
 a clinical context and relevance to basic
sciences learning.
 It also facilitates early involvement in the
healthcare environment that serves as
motivation
 reference point for students, leading to
their professional growth & development.
 Objectives
(a) Recognize the relevance of basic sciences in
diagnosis, patient care and treatment
(b) Provide a context that will enhance basic
science learning
(c) Relate to experience of patients as a
motivation to learn.
(d) Recognize attitude, ethics and professionalism
as integral to the doctor-patient relationship
(e) Understand the socio-cultural context of
diseases through the study of humanities
 Elements:
 a) Basic science correlation: To apply and
correlate principles of basic sciences
 b) Clinical skills: To include basic skills in
interviewing patients, doctor-patient
communication, ethics and professionalism,
critical thinking and analysis and self-learning
 c) Humanities: To introduce learners to a
broader understanding of the socio-economic
framework and cultural context within which
health
 Where to use
ECE?(implementation)
Case discussions
Patient brought to classroom
CONTEXT RELEVANCE
Classroom
setting
Training in basic clinical skills
Demonstration of clinical problems
Hospital Community
setting setting
Hospital visit
Community visits
Primary care exposure
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 Classroom setting
 Patient
 Paper cases
 Photographs
 X rays
 Lab reports
 ECG with/out clinician

Eg : thyroid hormone in physiology or

biochemistry classroom/group discussion
 Hospital settings
Small groups – to hospital
CVS –MR/MS/CHF/ECG
Endocrine system: hypo/hyperthyroidism
Anaemia, Jaundice
Learning objectives , guide .
1. Familiarrise them with clinical envronment
2. Create awareness
3. Observe doctor patient relationship
 Community settings
Rural areas eg : hygiene ,nutritional problems,
living condition of patients..etc
Helps
a. Behavioural and social sciences and ethical
dimensions of patient – doctor relationship.
b. preventive aspects of Medicine.
c. socio-clinical relevance and context to the
students
Structure of the program for students
 ECE in first year 90 hours
 Each subject is 30 hours.
1. Basic sciences correlation (18 hours):
One three hour session per month for 6 months
The clinical context
Actual patient contact
Paper based cases, charts
Graphics ,or photos
Videos
Reports (e.g. blood/urine reports , biochemical
markers),
Field visits etc. in community/ hospital laboratories.
Examples of clinical context and related learning
outcome
Clinical Context Outcome

COPD (Respiratory Physiology) 1. Demonstrate understanding of

Patient/video/investigations alterations in normal respiratory
physiology and anatomy in chronic
obstructive lung disease and their
clinical expression.
2. Explain the concept of restrictive and
obstructive lung disease
Claw hand, Foot drop, Carpal tunnel 1. Demonstrate understanding of
syndrome (Peripheral nerve injuries) alterations in normal anatomy &
Patient/ video function of these nerves and their
clinical expression. 2. Observe tests for
eliciting normal function of these nerves
 2. Clinical skills (12 hours):
 Three hour session per month for 4 months per
department may be allotted.
 Cases may be demonstrated by preclinical faculty
or clinicians
 small groups.
Each 3-hour session of clinical experience
1. Introduction to the module & instruction by
preclinical faculty: 30 minutes
2. Clinical experience (guide observation/checklist):
1 hour 30 minutes
3. Summary & conclusion (with learning points): 30
minutes
4. Reflection (with guidance & monitoring) on what
was learnt: 30 minutes.
Example of the The students should be able to compare
Disease / Disorder abnormal and normal

Pleural Effusion Position of mediastinum, findings on percussion,

abnormalities of breath sounds

Arthritis Swelling / Oedema & tenderness in the affected

joint, restricted & painful joint movements
 ECE Module 1:
 Acute Myocardial Infarction (AMI)
 Setting: Class room
 Topic of Basic Science: Coronary
Circulation
 ECE through- Acute Myocardial Infarction
case(Paper based case / Role play)
 Goal: The student must be able recognize
the relevance of coronary circulation in
diagnosis, patient care and treatment of
Acute MI
Expected Competency
1. Demonstrate understanding of alterations in
normal anatomy and physiology of coronary
circulation and its clinical expression.
2. Correlate the clinical manifestation in
myocardial infarction with altered coronary
circulation
3. Explain the basis and rationale of
biochemical tests done in myocardial
infarction.
 Objectives:
1) Describe the mechanism of regulation of
coronary circulation.
2) Describe the role of lipoproteins in
derangement of coronary circulation.
3) Explain the biochemical changes occurring in
acute myocardial infarction
4) Identify the clinical manifestation secondary
to decreased coronary circulation.
Learning Experiences: 3hours
 Introduction and instruction to students: 20
mins.
 Exposure to clinical context and
discussion:90 mins
 Summary and conclusion: 10 mins
 Reflection: 30 mins
 Assignment: 30 mins
ECE: Classroom setting: 3 hours
Clinical Context:
A 48 year old company executive experienced a sudden,
crushing chest pain, after he returned from his morning walk.
His wife noticed that he was pale, sweating profusely and was
in distress.
She rushed him to the ICU of a nearby hospital immediately.
He told the attending physician that on previous occasions
too he had felt such pain but he it had subsided with rest. He
is known smoker.
He also suffers from diabetes, dyslipidemia and hypertension.
ECG was taken & it showed ST elevation in leads II, III and
AVF. He was admitted in the ICU. *
This clinical scenario can be either used as a paper based case
or be performed as a role play if feasible.
Facilitator’s guide:
 What is the probable reason for the severe
pain in chest?
 Why did the regulatory mechanisms fail to
meet increased demand of Oxygen ?
 How are diabetes Mellitus, hypertension and
cardiac ischemia related?
 What do the changes in ECG indicate?
Lab report:
Various investigations carried out 4 hours
after the onset showed
Raised cardiac specific troponin T & I
Raised CK-MB - Raised Cholesterol (Total,
LDL and Triglycerides) *
Facilitator’s guide:
Why are the cardiac Biomarkers raised?
What do the serum lipid levels indicate?
What is the role of dyslipidemia in disruption
of coronary circulation?
What will be the next steps to manage acute
MI?
 Formative assessment: Submit assignment on
the topic anatomical and physiological basis
of treatment of acute myocardial infarction.
Reflections can be structured using the
following guiding questions
 What happened? (What did you learn from
this experience)
 So what? ( What are the applications of this
learning)
 What next? (What knowledge or skills do
you need to develop so that you can handle
this type of situation?
Program Evaluation: Feedback from
students to evaluate for improvements in
the module
1. How helpful has the ECE module been in
improving your knowledge about coronary
circulation?
2. Which components of the program helped
you to learn?
3. Did the ECE module make learning basic
science subjects more interesting?
4. Are you motivated to read further on this
topic as a result of participating in ECE?
5. Suggest changes in the program that will help
you learn still better.
 Humanities: This will be merged with
AETCOM module and therefore no
additional time is allotted
Formative & Internal Assessment
A)Internal Assessment:
During assessment, questions should test
clinical correlation in basic sciences.
B) University Examinations:
The Modified Essay Questions (Problem based
long answer questions),
Clinical vignette based Short Answers
Questions (SAQ),
objective type questions (e.g. Multiple Choice
Questions - MCQs)
OSPE can include parts of ECE.
Words of wisdom
Benjamin Franklin
 Tell me and I forget ,
 Teach me and I may remember
 Involve me and I learn