Validating the effectiveness of a classroom-setting form of early clinical exposure with direct physician involvement in gastrointestinal physiology education (2025)

Background

Early clinical exposure (ECE) represents one form of vertical integration that bridges the gap between the early theoretical years and the clinical practicing years in undergraduate medical education. In most medical colleges in China, the complex healthcare system and large-enrollment classes pose significant challenges for implementing ECE in a hospital setting. However, there is a paucity of data comprehensively demonstrating the effectiveness of a classroom-setting form of ECE with direct physician involvement in physiology education.

Methods

181 sophomore clinical medicine students from Harbin Medical University were randomly divided into two groups: a control group (n = 91) and an experimental group (n = 90). The control group received traditional flipped classroom (FC) teaching, whereas the experimental group participated in ECE teaching, which featured a gastroenterology physician and real patient cases in their final class session. Upon completion of the classes, both groups took a posttest. At the end of the semester, both groups were assigned the task of writing an original science communication on any physiology-related topic. The effectiveness of ECE was assessed by comparing posttest scores, the frequency of online self-directed learning, and the number of science communications addressing the digestive system between the two groups. Additionally, a questionnaire was administered to assess the experimental group's perceptions of the ECE teaching method.

Results

The posttest scores and the rates of excellence for the two groups showed no statistical differences. Although no difference was found in the frequency of self-directed learning between the two groups during the gastrointestinal physiology classes, the experimental group exhibited a frequency of self-directed learning that was more than twice that of the control group on the day following the physician's lecture. Furthermore, the number of science communications focusing on the digestive system was significantly higher in the experimental group compared to the control group (17/73 vs. 8/83, P < 0.05). In the questionnaire, more than 94% of the students expressed positive attitudes towards classroom-setting form of ECE with direct physician involvement and expressed a desire for this method to be applied in other chapters of physiology.

Conclusions

The classroom-setting form of ECE with direct physician involvement may not demonstrate immediate impact, but it encourages active learning, facilitates understanding of the subject's relevance, and enhances students' value output.

The learning content of physiology is logical and abstract, which poses a challenge for undergraduate students, especially for those majoring in clinical medicine who tend to focus more on the abnormality of diseases while ignoring the normal function. Thus, competency-oriented physiology teaching has been attempted at Harbin Medical University. On the basis of hybrid teaching, case-based learning (CBL), role-playing situational teaching, and flipped classroom (FC) teaching were implemented [1, 2], and emphasis was placed on assessments concerning ability and attitude dimensions. Although these teaching reforms have received positive feedback from students, their yearning for real clinical experience has not been fully satisfied.

The concept of early clinical exposure (ECE) has evolved beyond its initial narrow definition of patient contact solely within a clinical environment during the preclinical period [3]. Broadly speaking, it represents a form of vertical integration between preclinical and clinical subjects [4], implemented through diverse methods across classroom, hospital, and community settings [5].ECE has been proven effective in enhancing students' academic performance, clinical and communication skills, and in boosting their confidence [6,7,8,9,10,11]. The Medical Council of India introduced compulsory ECE sessions into the undergraduate medical curriculum starting from 2019 [12]. However, when attempting toimplement ECE in hospitals and communities, it was found that high patient loads, low doctor-patient ratios, and a large number of students made the logistics of such endeavors daunting [13]. Similar to India, China has a large population and a complex healthcare system, and most of its higher medical colleges have large classes in undergraduate physiology education.Notably, a recent review of 31 articles on ECE excluded any research conducted in China [14], suggesting difficulties in implementing ECE within a hospital setting. Therefore, we have chosen to initiate ECE in the classroom setting as a foundational step towards its further development. In our traditional FC teaching, the physiology instructor was responsible for designing and presenting clinical cases or problems. It is worth noting that the majority of physiology faculty lack clinical experience. As a result, students acquire knowledge and skills under their guidance but less in terms of attitude and professional identity. Given these limitations, we tend to introduce physicians to directly participate in the teaching process.

While the application of ECE in a classroom setting using various resources has been previously reported [9, 15, 16], the implementation of ECE in a physiology classroom setting with the direct involvement of physicians has not been thoroughly investigated. Moreover, no prior studies have comprehensively evaluated the impact of this classroom-setting form of ECE on students' knowledge, abilities, and attitudes.

Consequently, in the present study, we integrated ECE into traditional FC teaching for gastrointestinal physiology. The program was collaboratively schemed and implemented by a physiology instructor and a physician, focusing on actual patient cases and clinical experiences. The effectiveness of ECE was evaluated through posttest scores, the completion of self-directed learning and practical assignments, as well as students' perceptions and feedback.

Subjects

The study was conducted among sophomore clinical medicine students at Harbin Medical University in 2022. A total of 587 students were enrolled and divided into six teaching classes, each comprising over 90 students. We randomly selected two classes: one received traditional FC teaching (control group, n = 91), and the other received ECE teaching (experimental group, n = 90). The students had all passed the entrance exam and were admitted to a five-year undergraduate clinical medicine program, which consists of two years of preclinical studies and three years of clinical studies. The preclinical stage, conducted at the university, covers basic sciences such as anatomy, histology, embryology, biochemistry, physiology, pathophysiology, pathology, and pharmacology. The clinical stage takes place at the affiliated hospital, with the final year dedicated to a department rotation internship.

Intervention

Both FC and ECE teaching were based on a hybrid model, requiring students to complete self-directed learning and pre-class tasks. In face-to-face classes, students engaged in presentations, problem-solving, and case discussions under faculty guidance. The primary resource for autonomous learning was a physiology online course created by our team (https://www.xueyinonline.com/detail/232545944), which could be accessed via the "Xuexi Tong" mobile app.

The two groups were taught by the same experienced teachers using the same syllabus. As shown in Fig.1, the theoretical knowledge and clinical application content of the entire gastrointestinal physiology module were essentially identical in both groups. However, the learning content, teaching methods, and instructors arranged for each lesson were adjusted. Specifically, the theoretical content in the first two lessons of the ECE teaching group was greater than that of the FC teaching group, enabling comprehensive utilization of knowledge through case studies in the final class. In the control group, clinical questions and cases were designed by the physiology instructor and discussed under the guidance of the physiology instructor. The presentations of clinical scenarios were mainly based on text descriptions and images sourced from the Internet. In contrast, the clinical problems and cases in the experimental group were designed collaboratively by the physician and the physiology instructor, with joint instruction provided by both faculties during the final class. The physician introduced real-world scenarios through pictures and videos, drawing upon their own professional experience, while the physiology instructor activated prior knowledge at appropriate intervals.

Evaluation

To assess the effectiveness of applying the classroom-setting form of ECE with direct physician involvement, advancements in knowledge, skills, attitudes, and emotions were compared between the two groups. After completing the gastrointestinal physiology module, a posttest was administered to assess students' comprehension of theoretical knowledge and clinical application. Posttest scores and excellence rates were evaluated for both groups. The posttest comprised 18 single-choice questions and 2 multiple-choice questions (20 points in total), sourced from the Chinese National Medical Licensing Examination database. Questions related to digestive system physiology were meticulously selected and suitably adapted. To assess the promotion of active learning, we compared the daily frequency of online self-directed learning (measured by the number of students accessing the information) derived from "Xuexi Tong" during the duration of the gastrointestinal physiology course. To cultivate students' social responsibility, a science communication practice assignment based on any physiology topic of interest was required to be submitted upon completion of the entire course. The number of topics related to the digestive system was compared between the two groups. Additionally, a questionnaire survey was conducted to evaluate students' opinions regarding the ECE teaching.

Data analysis

All analyses were performed using IBM SPSS Statistics 21. The posttest scores were expressed as mean ± standard error (SEM). Comparisons of the mean posttest scores and the online self-directed learning frequencies between the two groups were performed using independent samples t-tests. Comparisons of the rates of excellence were carried out using chi-square tests. The proportions of students who attained excellence in the posttest and those who authored science communications about the digestive system were compared using chi-square tests. A p-value of less than 0.05 was considered statistically significant.

ECE teaching had no significant effect on students' performance in the posttest

To evaluate students' self-directed and instructor-guided deep learning, the posttest was conducted on the second day after the completion of the gastrointestinal course. Posttest scores were compared between the experimental group and the control group. No significant difference was found between the two groups in terms of average scores (17.34 ± 2.06 in the experimental group vs. 17.34 ± 2.08 in the control group, P > 0.05) (Fig.2A). Further analysis of the distribution of scores revealed no difference in the rate of excellence (scores above 18) between the two groups (65.6% in the experimental group vs. 63.7% in the control group, P > 0.05) (Fig.2B).

ECE teaching facilitated active learning

The student-centered pedagogical model emphasizes active learning, which depends on students' self-directed learning ability. Our self-developed online physiology course serves as the primary resource for students' autonomous learning. Thus, we conducted a comparison of the frequency of active learning between the two groups, as automatically recorded by the "Xuexi Tong" platform. From the initial class to the final class, there was no difference in the frequency of self-directed learning between the two groups (84.00 ± 41.07 in the experimental group vs. 103.83 ± 50.02 in the control group, P > 0.05) (Fig.3). However, intriguingly, on the second day of ECE teaching with direct physician involvement, the frequency of self-directed learning in the experimental group was more than twice that of the control group (237 vs. 112) (Fig.3).

ECE teaching improved students' output of science communications

The dissemination of health science knowledge to the public is an obligatory responsibility for medical students. Consequently, at the end of the semester, students were tasked with composing a science communication piece focusing on a specific aspect of physiology. We analyzed the distribution of these science communications based on their topics. As shown in Fig.4, the number of topics related to the digestive system in the experimental group was significantly higher than that in the control group (17/73 vs. 8/83, P < 0.05).

Students’ perceptions on ECE teaching

A questionnaire was conducted in the experimental group with a recovery rate of 98.9%. The results indicated positive attitudes (including strongly agree and agree) towards ECE teaching, ranging from 94.4 to 98.9% (Table1). Regarding physicians directly involved in classroom teaching, 98.9% of students perceived that the real cases shared by physicians were more engaging than the cases presented in traditional teaching. Additionally, 97.8% of students believed that the involvement of physicians improved their understanding and expectations of clinical work, thereby enhancing their learning interest and motivation to study. Over 96% of students found ECE teaching helpful in understanding theoretical knowledge, expanding the depth and breadth of their knowledge, and enabling them to use basic sciences to analyze and solve clinical problems. Furthermore, 98.9% of students recognized that basic sciences learning was crucial to becoming a clinician. Most students perceived that ECE teaching improved their skills and abilities, including self-study ability (95.5%), as well as teamwork and communication skills (94.4%). At the end of the questionnaire, 97.8% of students expressed a desire for this method to be applied in other chapters of physiology.

The present study demonstrated that the classroom-setting form of ECE, with direct physician involvement, was effectively integrated into the physiology course. ECE teaching enabled students to see theory in practice, activated their intrinsic motivation for learning, and promoted value output, all of which were highly accepted by students.

Classroom-setting form of ECE with direct physician involvement serves as aviable strategy for bridging theory and practice

Reports from the Lancet Commission (2010) and the Howard Hughes Medical Institute emphasized the implementation of competency-based medical education (CBME), including reforms in teaching styles [17]. The integration of ECE into medical education has since gained widespread acceptance and promotion in numerous countries worldwide. Although ECE is believed to be beneficial, there is a risk that it could be perceived as a "quick fix" for a lack of clinical experience, rather than as an integral part of a broader educational program [14]. A pilot study involving 60 students defined a learning framework for ECE in a physiology course, incorporating bedside clinics and observations. However, the authors acknowledged logistical difficulties in applying this framework to a larger class of 150 students and suggested utilizing information technology and real-time applications to reduce the number of hospital visits while enhancing students' clinical experience within the classroom setting [18].

In 2018, China's Ministry of Education proposed to strengthen the Excellent Doctor Education and Training Plan through medical and educational cooperation, aiming to promote competency-oriented teaching reform. The collaboration between basic science faculty and clinical teachers in a classroom setting in this study represents a novel endeavor. It is not constrained by student numbers and maintains the overall curriculum framework, demonstrating strong feasibility. The examination content of the Chinese National Medical Licensing Examination reflects the latest requirements and development trends in medical education and clinical practice. To align with the competency levels of the subjects and focus on core physiological knowledge, the posttest questions were carefully curated by making appropriate adjustments to authentic items from a databank. In terms of cognitive dimensions, these questions primarily encompassed memory, comprehension, application, and analysis, falling short of the levels of evaluation and creation. This may have contributed to the absence of statistically significant differences in performance between the two groups of students in the posttest. This result also suggests that our traditional FC teaching is helpful for the acquisition of physiology core concepts and foundational clinical applications, and the impact of ECE may not be immediately apparent. Notably, despite ECE teaching devoting more effort to presentation formats and medical humanities, it did not compromise students' mastery of foundational knowledge. In the questionnaire, students highly acknowledged the role of ECE teaching in fostering the integration of theory and practice and exhibited greater interest, revealing that ECE serves as a viable strategy for bridging theory and practice in the preclinical stage of medical education.

Classroom-setting form of ECE with direct physician involvement activates students' intrinsic motivation for learning

Intrinsic motivation is created when the relevance of the subject matter serves as the primary driving force [19], and it drives students' active learning. Active learning strategies range from introducing a small number of peer discussion questions into class time to fully "flipping" the classroom by transmitting content before class and utilizing lecture time for student practice and reinforcement [20]. Self-directed learning is the cornerstone of successfully implementing FC or ECE teaching. In our study, both groups of students were provided with identical online learning resources via "Xuexi Tong", which included micro-lecture videos, knowledge outlines, courseware, and exercises. We were pleasantly surprised to observe that, following the implementation of ECE with direct physician involvement, the number of students accessing "Xuexi Tong" for self-study doubled compared to the control group.Although some studies have assessed the effectiveness of ECE in areas like respiratory, renal, and endocrine physiology using questionnaires [13, 21, 22], none have provided quantitative evidence on its role in promoting students' self-directed learning. The present study was pioneering in utilizing information technology to demonstrate that our ECE teaching promoted active learning, potentially due to the activation of students' intrinsic learning motivation, which was consistent with subjective feedback from students.

Classroom-setting form of ECE with direct physician involvement promotes students' value output

Learning effectiveness refers to any advancement in knowledge, skills, attitudes, and emotions after completing the course [23]. A comparative analysis of ECE studies conducted in various countries revealed that attitude was a common domain covered by all the studies [14]. However, evaluating the attitude and emotion dimensions of objectives presents significant challenges. Given that assessment procedures in CBME emphasize attitude and skills more than knowledge, shifting from measuring input to measuring output or outcome [24], we have incorporated science communication practice as a key criterion for evaluating students' attitudes and ability output since 2021. We have established practical platforms such as science communication competitions and official health science communication WeChat accounts [25], while also integrating science communication practice assignments into the summative assessment. Based on the questionnaire results, we believe that the larger quantity of topics related to the digestive system in the ECE teaching group might be attributed to ECE teaching fostering a sense of professional identity, thereby promoting students' value output.

Study limitations

Several limitations of the present study need to be considered. First, due to physicians' busy clinical schedules, their participation in face-to-face classroom teaching was limited. Future efforts should focus on enhancing the depth and breadth of physicians' involvement by fostering stronger inter-departmental cooperation. Second, while students' grasp and application of theoretical knowledge were assessed through a posttest, the number and difficulty of the questions were insufficient to fully evaluate their ability to integrate theory with practice. The long-term impact of classroom setting form of ECE on students' professional competence warrants further investigation. Lastly, although we compared the frequency of self-directed learning between the two groups using "Xuexi Tong" records, the duration of self-directed learning was not included as an evaluation criterion due to technical limitations.

ECE:

Early clinical exposure

FC:

Flipped classroom

CBL:

Case-based learning

CBME:

Competency-based medical education

Author notes

1. Yan Yan and Lihong Hu contributed equally to this work.

Authors and Affiliations

1. Department of Physiology, School of Basic Medical Sciences, Harbin Medical University, 157 Baojian Rd, NangangHeilongjiang, 150081, Harbin, China

   Yan Yan,Ying Zhang,Bo Cao,Yujia Huang,Jiao Wang,Haixia Wen&Hui Zhu

2. Department of Gastroenterology, Second Affiliated Hospital, Harbin Medical University, 148 Baojian Rd, NangangHeilongjiang, 150000, Harbin, China

   Lihong Hu

3. Department of Anesthesiology, Second Affiliated Hospital, Harbin Medical University, 148 Baojian Rd, NangangHeilongjiang, 150000, Harbin, China

   Qiang Zhou

Contributions

H.Z. and H.W. contributed to the study design; Y.Y., L.H., Y.H. and Q.Z. contributed to the study investigation. Y.Y. and Y.Z. wrote the first draft; H.Z. and B.C. contributed to the revision of the paper; J.W. and Y.H. contributed to the interpretation of data. All authors have read and approved the manuscript.

Corresponding authors

Correspondence to Haixia Wen or Hui Zhu.

Ethics approval and consent to participate

This study was approved by the Department of Physiology at Harbin Medical University. The Ethics Review Committee of Harbin Medical University deemed this project as non-human-subjects research, in accordance with the Ethical Review Measures for Life Sciences and Medical Research Involving Human Beings (issued by the National Health Commission, Ministry of Education, Ministry of Science and Technology, and Administration of Traditional Chinese Medicine on February 18, 2023). Verbal informed consent for the survey was approved by the Ethics Review Committee of Harbin Medical University and was obtained from each participant. All data collected from the participants were kept anonymous to protect their privacy.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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