Early clinical contact in the medical undergraduate...
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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
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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
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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The actual experience
of a new integrated curriculum
at Sapienza, University of Rome,
since 1999.
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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The course of
Medical Scientific Methodology
and Medical Humanities
At Sapienza, University of Rome, since 1999…….
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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, Med. Chir. 2000; Familiari et al., Med. Chir. 2006
Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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, Med. Chir. 2000; Familiari et al., Med. Chir. 2006
Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000;
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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•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!
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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:
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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In the hospital setting
at bedside and ambulatory care
The Early Clinical Exposure program
at Sapienza, University of Rome, since 1999.
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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First Year Course
At Sapienza, Early Clinical Exposure program comprised:
Familiari, Med. Chir. 2000; Familiari et al., Med. Chir. 2006
Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000;
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”).
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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Second Year course
At Sapienza, Early Clinical Exposure program comprised:
Familiari, Med. Chir. 2000; Familiari et al., Med. Chir. 2006
Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000;
• 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.
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);
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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, Med. Chir. 2000; Familiari et al., Med. Chir. 2006
Familiari et al., AMEE Conference 2008, 2009; Torsoli et al. MEDIC, 2000
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)
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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• 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
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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
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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:
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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)
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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?
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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.
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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
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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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.
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013
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Thank You for your attention!
Conferenza Permanente CLMMC: 110^ Riunione, Palermo, 22 Marzo 2013