This document describes an early clinical exposure (ECE) curriculum implemented at medical schools in Slovenia. [1] The curriculum introduces first-year medical students to patients through a "Communication" course. [2] Students learn communication skills through lectures, role-playing exercises, interviewing nursing home residents, and observing general practitioners. [3] Feedback from students and teachers was positive, finding the ECE educationally effective and helping students develop confidence and identity as future physicians. However, some challenges around student preparedness and assessment subjectivity were noted.

1. Early clinical exposure in primary
care – an experience from Slovenia
Marija Petek Šter
Igor Švab
Janko Kersnik
Nena Kopčavar Guček
Zalika Klemenc Ketiš
Davorina Petek
Department for family medicine
University of Ljubljana
Slovenia
Department for family medicine
University of Maribor
Slovenia

2. Content
• Introduction by participants ( 10’)
• Short presentation of Slovenian ECE curricula:
background, presenting our experiences
about early clinical exposure (ECE) (30’)
• Buzz grope (three participants) – discussing
about the situation on their own faculty
( country) (30’)
• Plenary discussion with presenting different
experiences and ideas (20’)

3. ECE- background
• Early clinical exposure (ECE) helps medical
students to develop appropriate attitudes
towards their learning and future medical
practice.
• ECE increase the student’s motivation for
theoretical studies
• opportunity for improving communicacion skills
• hepful in established a good doctor-patient
relationship and understand the patient as a
human beeing

4. ECE – background
• Traditional medical schools: two or three years elapse
befor students come into contact with patients
• Modern medical schools: Early contact with patients
• BMJ 1976: description of Early medical contact in
Southampton (Grat Britan): introduce students to a healthy
women during pregnancy, labor, the puerperium and
during the six weeks after delivery.
• Many medical schools practice ECE in the first two years of
the undergraduate course.

5. ECE in general practice
• Communication is a core element of general
practice
• GPs can make important contributions to
teaching of interviewing skills, even to students
with minimal clinical experiences
• Students find the environment of general
practice supportive and appreciate the variety of
patients seen and individual tuition.
• GP’s : emotional needs: contact with enthusiastic
students and gain in self-esteme

6. ECE in Slovenia
• Changes of curriculum in medicine and dental
medicine at Medical faculty Ljubljana 2009/10
• Before 2009: the firs contact with patient in the 3rd
year (propedeutics)
• New curriculum at the Medical faculty of Ljubljana
introduced early clinical exposure for the first year
medical students through the subject
“Communication”.
• Decision for the introduction of this subject is based
on the empirical recognition of the fact that previous
programme lacked the necessary knowledge and
experience for good interpersonal communication

7. Aim of ECE
• To teaching and learning medical students
about the importance of communication in
contact with patient, to teach the basic
principals of communication with people and
patients and help students to understand that
good relationship with patients and colleagues
are of outmost importance for effective
treatment.

8. Objectives of ECE
• Providing students with the basic knowledge
on medical psychology
• teach them how to communicate with
healthy people and patients
• present them the rules for communication
within a small group
• help to understand that good doctor-patients
relationship is crucial for the successful
treatment.

9. Structure of the curriculume
• 4 credits
• Mandatory for students of medicine and dental medicine
• 1st semester ( 300 students)
The curriculum consists of:
• theoretical part (lectures from medical psychology)
• practical part (communication in a small group using prepared
vignettes, interview with nursing home residents and observation
of general practitioners' work during their 1-day practice
attachment).
Faculty:
• Cooperation between Department for psychiatry and Department
for family medicine
• External Collaborators: nursing homes staff and tutors in the offices

10. Teaching methods
• Lectures
• Seminars
• Small group work
• Fieldwork (nursing home)
• Individual work (seminar, report from clinical
visit)
• Clinical visit
• Discussion with feedback

11. Lectures
• Basic knowledge about medical psychology
• Basic knowledge about communication with
people and patients (verbal and non-verbal
communication)

12. Seminars
• Characteristics of elderly people (nursing home
residents) and communication with elderly
• ( taking into account their health related
problems)
• Presentation of the protocol for semi-structured
interview with nursing home resident
• Behavior in the office and ethical principle of
physicians work
• Presenting the protocols for observing
communication in the office

13. Small grupe work
• Communication in a small group (12-14 students) using
prepared vignettes:
• Presenting the method
• Demonstration of role play and effective feedback
• Role play in a group of three students using three
different vignettes (alcohol related problems, obesity,
lose of the partner) including feedback
• Role play: Presenting the interview with nursing home
residents
• Final remarks, questions…

14. Fieldwork
• Interview with nursing home residents:
• Six to eight nursing homes in a neighborhood of the
Medical faculty - contraction with Medical faculty
• Nursing home staff: rules of behavior, ethical principals
• Students in pairs: one of the student performing a
semi-structured interview according to the instructions
and the second one is an observer
• One hour time for each interview
• After the firs interview with the firs patients, the role
with the second patient was changed ( an observer
became an interviewer)

15. Individual work
Seminar about visit in the nursing home
Four part:
• Data gathering (reasons for admition in nursing home,
typical day, physical problems, psychical problems,
medication, functional status, relations to relatives, staff
and other residents)
• Analysis - the main problems of the resident and potential
solutions
• Analysis communication of the colleague
• The main gain, feelings or fears related to the visit in
nursing home
Analysis of the communication between patient and general
practitioner in the office based on the protocols

16. Clinical visit
• One day attachment in general practice
• General practices all over Slovenia (choose by
the student, tutors trained in giving feedback)
• Student is an observer of general
practitioner’s work and communication
• Protocols for observation (20 consultations)

17. Protocol for observing general
practitioners work and communication

18. Discussion with feedback
• Small group work with presenting the
seminars with feedback
• Discussion about the experiences from
communication with patients

19. Assessment
• Students have to pass theoretical and
practical part of the exam. Each part
contribute 50% of final mark
• Theoretical part: MCQ questions ( 60% of
points)
• Practical part: Seminar and analysis of the
communication at office visit (written, oral),
criteria for evaluation was prepared in
advance

20. Students feedback
• During the curriculum: we appreciated
students’ oral feedback
• On the end of the curricula: students written
feedback with the evaluation of the overall
curricula and parts of the curricula using
evaluation form (Likert scale 1 to 5)
• Students feedback is of most importance for
future improvement of the curricula

21. Students’ feedback and assessment of
the curricula - overall
• Student’s assessed ECE as of outmost
important for their personal and professional
development
• They found that good relationship is
important part of treatment
• They would like to have more practical work
and oportunity for communication

22. Students’ feedback and assessment of
the curricula -Interview with nursing
home residents
• Fears that their skills of communication is
inadequate (welcome and respect by the staff
and patients)
• Emphatic relationship with the elderly
• They found that elderly people are much
more positive and more vital in their mind
that they think before
• An opportunity to learn from life experiences
of elderly people

23. Students’ feedback and assesment of
the curricula –office visit
• White coat – they found themselves as future
physicians
• They found that the physicians work is
complex with many dilemmas
• Motivation for future study
• Confirmed that decision to became physician
is appropriate

24. Teachers and tutors experiences
Positive experiences:
• feasible to organize: enthusiasm of the staff in
nursing homes and offices
• acceptable to patients: most of the patients find
the ECE as important and participate in the
curricula,
• educationally effective: students greately valid
their extensive contact with patients
Evaluation: subjective in assessing of practical part
of the curricula

25. Dilemmas
• Inadequate knowledge and experiences in
communication
• Personal immaturity: problems with
acceptance of professional and ethical norms
• Interview with elderly nursing home residents
is too demanding (no knowledge about the
characteristics of residents, problem with
empathy, dealing with emotional reactions,
ethical issues)

26. Plans for the future
• More opportunity for practice communication
• Assessment of practical part should be more
objective
• Study literature – a textbook for students
• Communication as a part of curriculum in
each study year (to prevent erosion of
empathy in clinical years)

27. Conclusions
• Student’s assessed ECE as of outmost important for
their personal and professional development
• Teachers have positive experiences: feasible to
organize, acceptable to patients, educationally
effective
• EPC motivate and satisfied students of the health
professions and helped them acclimatize to clinical
environments, developed professionally, interact with
patients with more confidence, and less stress,
developed self reflection and professional identity.
They mad them more real and relevant to clinical
practice.

28. Buzz
group work
• Three participant from different medical
schools (countries)
• In brief present you curricula about ECE and
your experiences
• Compare your experiences to the others
• Prepare points for discussion