Early clinical contact in the medical undergraduate Curriculumpresidenti-medicina.it/wp-content/uploads/Familiari-early-clinical... · clinical methodology, EBM principles, the appropriate

G. Familiari1, L. De Biase1, G. Nati2, G. Grasso2, V. Ziparo1, C. Della Rocca, P. Gallo, F. Consorti, E. Gaudio, A. Lenzi

Early clinical contact in the medical undergraduate Curriculum

at Sapienza University of Rome: Fourteen years’ experience

1 Sapienza University of Rome, Rome, Italy 2 Italian Society of General Practice/Family medicine, Rome, Italy

Jippes and Major reported that in Italy the rate of Medical

Schools with PBL integrated curriculum was 0%!!

De Benedictis, Ann. Comm. Orient Educ., 1990, Binetti et al., MEDIC,1998

Torsoli et al., MEDIC 2000; Torsoli and Frati, MEDIC 2002; Jippes and Major, Med. Educ. 2008

Nevertheless this experience and other similar at Bari

University and Campus Biomedico University of Rome…..

Sapienza University of Rome 1993

Rome Parallel Track introduced PBL and vertical integration

devoted to a small group of students.

Prof. Aldo Torsoli

Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013

Do really exists vertically integrated and PBL based

undergraduate curricula in Italy?

Do really exists early clinical exposure in the

undergraduate curricula in Italy?

It is noteworthy that over the last ten years, the

National Board of Medical Degree Course Heads has

sponsored larger efforts to pursue curriculum

innovation in this field!

Danieli, MEDIC 2000; Lenzi et al., Med. Chir. 2008


The actual experience

of a new integrated curriculum

at Sapienza, University of Rome,

since 1999.


in order to develop a biomedical-psycho-social profile

in medical students

At the same time was introduced a program of

early clinical exposure (ECE)

placed in the beginning three years course

Familiari, Med. Chir. 2000; Familiari et al., Med. Chir. 2006

Familiari et al., AMEE Conference 2008, 2009

we have activated a new vertically integrated and PBL based undergraduate

curriculum since 1999, at Sapienza, University of Rome



The course of

Medical Scientific Methodology

and Medical Humanities

At Sapienza, University of Rome, since 1999…….


Sapienza University of Rome: METHODOLOGY CFU Distribution

Year Semester CFU=47 1CFU=08hrs

Scientific Domains (Italian SSD “MED”)

I 1 7 MED 02-09, M-PSI08, M-DEA01,M-PED01

2 3 MED 01

II 1 3 MED 42, SPS07

2 6 MED 02-09-18-41-44

III 1 7 MED 09-18-10-45

2 7 MED 09-18-11

IV 1 2 MED 43, BIO 09-10-16

2 2 MED 42, BIO 09-10-16

V 1 6 MED 42-44

2 2 SECS-P06, BIO 09-10-16

VI 1

2 4 MED 43


The course of Medical Scientific Methodology

and Medical Humanities at Sapienza, University of Rome:

explicit vocation to integrate the curriculum

supported by linking it to early patient contact programs

in the first 3 years, and clerkship in the Hospital

and the community in years 4-6

attempt to anchor the basic sciences

to a vertical platform, where clinical studies

and public health develop

in the early phase of the curriculum


Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000


Emphasize the importance on humanistic studies,

the development of critical thinking and

self directed learning, teamwork,

and the concept of professionalism in medical practice

The course of Medical Scientific Methodology

and Medical Humanities at Sapienza, University of Rome:

a glue to join basic with clinical sciences

in the cultural context in Italy,

obtaining vertical integration


Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000;


•Clinical and communication skills

•Basic and clinical sciences

•Social, community and population health

•Personal and professional development

Early clinical exposure and vertical integration:

In an integrated curriculum, education and

clinical service are mutually enhanced!


Ai fini indicati i laureati della classe dovranno avere acquisito:

…. In particolare, specifiche professionalità nel campo della

medicina interna, chirurgia generale, pediatria, ostetricia e

ginecologia, nonchè di specialità medico-chirurgiche, acquisite

svolgendo attività formative professionalizzanti, per una durata

non inferiore ad almeno 60 CFU da svolgersi in modo integrato

con le altre attività formative del corso presso strutture

assistenziali universitarie….

DM270/2004 - LM/41 - Practical Skills:


Sapienza University of Rome: Practical Skills CFU Distribution

Year Semester CFU=60 1CFU=20hrs

Scientific Domains (Italian SSD “MED”)

I 1 1 MED 09 health district

2 1 MED 09

II 1 1 MED 09 health district

2 1 MED 09-41

III 1 3 MED 09-18-05 health district

2 3 MED 09-18-08

IV 1 7 MED 17-15-12-14-24

2 7 MED 11-22-10-13-35

V 1 7 MED 09-18-06-42-16 health district

2 7 MED 25-26-30-31-36-37

VI 1 10 MED 09-18-38-40 health district

2 12 MED 09-18-41-11-22-23-43


Low-tech simulation modalities

•Simple three dimensional organ models

•Basic plastic manikin and simple skills trainers

•Animal models

•Human cadavers

•Simulated or standardised patients

Teaching/learning in small groups Simulation based medical education

High-tech simulation modalities •Screen-based simulators

•Realistic, high-fidelity procedural simulators (endoscopy, etc..)

•Realistic high-tech interactive patient simulators

•Virtual reality

WELL developed

poor developed


Bedside teaching

•The learning triad: patients – students – tutors

Ambulatory care teaching

•Offers a variety of clinical situations and a range of common

clinical conditions not seen in inpatient care

“In the community” teaching

•Advantages in epidemiology, preventive health principles,

community impact of illness, communication skills, learning

about general practice and multiple disciplines concurrently

Teaching/learning in small groups Clinical skills apprenticeship – learning situations


In the hospital setting

at bedside and ambulatory care

The Early Clinical Exposure program

at Sapienza, University of Rome, since 1999.


First Year Course

At Sapienza, Early Clinical Exposure program comprised:



Recently (2008), an additional module has been introduced

in general practice, carried on the community setting

in collaboration with Italian Society of General Practice (SIMG);

A seven-ECTS integrated course devoted to

medical-patient-nurse communication skills,

in which students had a practical hospital setting module

with tutorial guided student-patient contact

(“psycho-social anamnesis”).


Second Year course

At Sapienza, Early Clinical Exposure program comprised:



• Students had basic medical and surgical practice modules

as well as basic life support using skill-lab.

• A six-ECTS integrated course concerning elements

of clinical methodology and EBM principles.



in collaboration with Italian Society of General Practice (SIMG);


Students had basic medical and surgical practice modules in

small groups with skills lab and bedside teaching.

Third Year course at Sapienza, Early Clinical Exposure

program comprised:

a fourteen-ECTS integrated course concerning

elements of clinical methodology, EBM principles, the appropriate patient-

doctor relationship, student’s communication skills, clinical epidemiology,

diagnostic reasoning, anamnesis, physical examination, clinical and

instrumental semeiotics (Skills lab and bedside)


Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000



in collaboration with Italian Society of General Practice (SIMG)


• Curricular clinical clerkships (Hospital ambulatory care

and bedside teaching) in all medical and surgical

disciplines;

• A clerkship in General Medicine (2/3 Weeks in the

private office of general practitioner and lessons at

University), mandatory since 2003.

ACTIVITIES OF PROFESSIONAL APPRENTICESHIP in the hospital setting at bedside, ambulatory care

and in the community

Fourth- sixth years


Early Clinical Exposure in General Medicine,

Since 2008

General structure

3 years long (first, second and third year courses)

Each year:

– 1-2 introductory lesson

– six half/days of participation in the private office

of the GM tutor


Students’ anonymous questionnaires (n=7312,

years 2009-2012) revealed a positive feedback:

•mean percentage satisfaction for ECE integrated

courses (1-2-3 Years course) = 84,7±2,8;

•mean percentage satisfaction for all integrated

courses of School of Medicine = 83,6 ±5,7;

t= 12,582; P≤ 0,0001

ECE Student’s perceived satisfaction at

Faculty of Medicine and Psychology,

Sapienza University of Rome:


Early Clinical Exposure can be defined as:

From BEME Systematic Reviews:

Littlewood et al., BMJ 2005; Dornan et al. Med. Teach, 2008

authentic human contact in a social or clinical context

that enhances learning of health, illness and/or disease,

and the role of the health professional occurring in the

early or preclinical years of undergraduate education

(usually the first two years)


Early clinical experience may contribute to

students’ satisfaction with medical education

Helmich et al., Medical Education 2012

Entering medical practice for the very first time:

there are large differences in the emotional talk,

meaning and identity development.

Medical educators should help students to be sensitive

to their emotions, offer space to explore different

meaniing, and be ready to suggest alternative

interpretations that foster the development of desired

professional identities.

Johnson and Scott, Acad Med 1998


Early experience helps medical students socialize to their chosen profession.

It can help learners attain a number of affective outcomes and acquire communication and basic clinical skills.

It can help make students more satisfied with their curriculum (motivate them) and confident to meet patients (reduce the stress of meeting patients).

It gives insight into psychosocial aspects of medical care and strengthens learning of both the biomedical and behavioural/social sciences.

It contextualizes students’ learning.

It can influence career choices.

It has potential benefits for teachers, healthcare organizations, patients and populations.

Littlewood et al., BMJ 2005; Dornan et al., Med Teach 2008; Julian et al., Acad Med 2011

How can experience in clinical and community setting

contribute to early medical education?


Why clerkship in General Medicine?

It is the setting in which the doctor-patient relationship acquires a higher

relevance

It allows to observe the evolution of diseases within their own context,

considering the associations among health, family and society.

It allows the contact with patients suffering the most common clinical

conditions (hypertension, diabetes, bronco-pulmonar diseases, etc.),

usually coexistent in a single patient, thus designing highly complex cases.

It allows to learn some simple semiologic manoeuvres.


Observed:

43 medical schools in 21 countries.

35 (81.4%) implemented ECE starting at the first year

33 (76.7%) starting during the first semester.

The duration of ECE program ranges from two weeks

to two years.

The number of sessions in each has rather wide scope,

changing from 1 to 60 sessions.

Length of each session takes two hours to full day.

A majority is placed in general practice/family medicine

Departments (35 schools). Başak et al., Eur J Gen Pract. 2009

Early clinical exposure in medical curricula in

family medicine across Europe: an overview


Conclusions

Our students clearly enjoyed this type of precocious

experience and perceived it as an important tool.

Take home message

The ECE program reinforces the social

responsiveness of clinical education, students

attitudes, clinical and study skills, orientating medical

curriculum towards society’s needs.


Thank You for your attention!


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Early clinical contact in the medical undergraduate Curriculumpresidenti-medicina.it/wp-content/uploads/Familiari-early-clinical... · clinical methodology, EBM principles, the appropriate