Liu et al.

BMC Medical Education (2022) 22:435

https://doi.org/10.1186/s12909-022-03505-5

RESEARCH Open Access

Impacts of early clinical exposure

on undergraduate student professionalism—a
qualitative study
Chun‑i Liu1, Kung‑pei Tang2, Yun‑chu Wang3 and Chiung‑hsuan Chiu4*   

Abstract
Introduction: Early clinical exposure (ECE), or authentic human contact in a social or clinical context during preclini‑
cal training, has been adopted by many medical schools. This study aims to investigate how medical students’ sense
of professionalism changed after ECE intervention, with the aim of informing curriculum design to enhance student
awareness of the importance of medical professionalism.
Method: Focus groups of ECE students were held to collect data for the study. All participants read interview
guidelines before starting. During the focus groups, the students discussed their medical obligations as perceived
throughout the course, which offered a choice between four different ECE tracks. They were then asked to report their
understanding of the situations they encountered during the course and reflect on their implications.
Results: Six focus groups of 22 students in total from a medical school in northern Taiwan were held shortly after the
students completed an ECE course in September 2019. From their responses, 10 categories relating to medical profes‑
sionalism were deduced categorized under 5 major dimensions. An additional 8 sub-dimensions on attitudes and
2 sub-dimensions on personal well-being were also identified as new categories separate from but related to medi‑
cal professionalism. After the ECE intervention, about 59% of participants redefined their understanding of medical
professionalism.
Conclusion: ECE and intensive interaction with key stakeholders, including patients and their families, help students
in the early stages of medical education form and cultivate a sense of medical professionalism. However, the relation‑
ship between participants’ personalities, motivations, and clinical activities requires further investigation.
Keywords: Medical professionalism, Medical humanities coursework, Early clinical exposure, Undergraduate medical
education

Introduction approach or the biopsychosocial model [1]. However,

It is difficult for medical educators to equip students with it was not until recently that a variety of curricula have
all the tools they will need in their future careers. Teach- been developed to cultivate medical professionalism
ers have proposed a variety of models to teach the many among medical students [2–6].
competencies required of a doctor, such as the scientific Medical professionalism plays an important role in
guiding physicians as they make daily clinical deci-
sions, practice ethics, and respond to societal expecta-
*Correspondence: [email protected] tions [7], yet its definition is difficult to pin down. Most
4
School of Health Care Administration, Taipei Medical University, Taipei, definitions cover a range of perspectives, including val-
Taiwan ues, attitudes, and behaviors [8, 9]. Some studies define
Full list of author information is available at the end of the article

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Liu et al. BMC Medical Education (2022) 22:435 Page 2 of 9

medical professionalism as a virtue or moral [10–12], This study therefore aims to clarify: (1) How students
while others expand its scope beyond ethics [8, 12, 13]. perceive of their own professionalism before and after
Referencing these various frameworks, Chiu formulated ECE intervention; and (2) What curricula best enhance
5 theoretical dimensions for medical professionalism, student awareness of medical professionalism.
each further divided into 3–4 theoretical categories [8].
This framework was developed based on medical culture
in Taiwan for use in investigating medical professional- Methods
ism among plastic surgeons [9] and medical students [8, Curriculum design
14]. By including previous definitions [15], this concep- This study focuses on a mandatory course entitled ‘Medi-
tualization provides a holistic interpretation of medical cine & Society: Theory & Practice’ offered at a medical
professionalism. school in northern Taiwan. Designed based on ECE con-
Another challenge lies in transferring an understand- cepts, students can choose to take 1 of 4 modules (A, B,
ing of medical professionalism from faculty to students. C, and D). Module A addresses situational learning in a
Some widely discussed approaches involve the reflective clinical setting by arranging for students to observe and
method [15], socialization, role models, service learn- interview residents at a nursing station. Module B focuses
ing, or natural proposition [13], although one other has on service learning in the community, namely construct-
been gaining ground in recent years. Derived from the ing a dementia-friendly environment by interviewing
Flexner Report [1, 16–18], early clinical exposure (ECE), healthcare providers and community members. Module
or authentic human contact in a social or clinical context C is held in an intensive care unit (ICU), and mainly deals
during preclinical medical training, has been adopted with ethical issues regarding ventilator usage on termi-
by medical schools worldwide to close the gap between nally ill patients by interviewing caregivers and patients’
basic and clinical sciences. Since medical knowledge and families. Module D emphasizes health promotion in local
professionalism are too intertwined to be learned in iso- communities. Direct clinical exposure totals 4–6 h in
lation [17], recent studies have shown that certain clini- each module, bookended by preparation beforehand and
cal practices have already been integrated into the early discussion with instructors afterward. After exposure,
stages of medical education throughout the world [1, 16, students are required to write a self-reflection their expe-
19–29]. While the term used to narrowly refer to formal rience. About 160 first-year and second-year medical stu-
clinical experiences early in medical school, ECE is based dents enroll in the course each year.
on a broad definition that includes community contact
[30, 31] and early student-patient contact [32–38], as well
as early clinical exposure [19, 20, 23, 29]. Reviews of ECE Study design
curricula have found that early exposures could consist To understand how effective the ECE course is at foster-
of supervised clinical placements and sometimes direct ing students’ sense of medical professionalism, this study
exposure to patients, their families, and the community held focus groups for students to discuss their experi-
[31, 39]. ECE could therefore refer to a variety of clinical ences. Focus groups were conducted after students com-
activities before official clerkships and internships. pleted the course in September 2019. Before the focus
Previous studies have documented the benefits of ECE groups began, all participants were expected to read the
[22, 40–43]. When incorporated into the medical sci- interview guidelines and reflect on their observations.
ences curriculum, ECE improved students’ academic The interviewer was trained before conducting the
performance [19, 21], while many studies have shown focus groups to ensure the consistency and quality of
its benefit in helping students translate medical knowl- data collected. Before obtaining informed consent from
edge into clinical practice [1, 19, 39, 41, 44]. Studies have participants, the interviewer prior to the study explained
also proven the efficiency of ECE in building a sense of its aims, participant confidentiality, and notified partici-
professionalism [13, 35, 39, 45]. As the beginning of pro- pants it would be audio recorded. Under the interview
fessional socialization, ECE is usually paired with men- guidelines, all interviewees were first asked what they
torship or role-model pedagogy [7, 46–49]. However, few know about medical professionalism, then were invited to
studies investigate the effect of ECE on students’ own recall their experience of the course’s on-site component.
perception of medical professionalism. They were then asked to describe at least one incident,
Recent studies have identified factors that contribute conversation, or event that affected them the most while
to a successful ECE experience, suggesting that the struc- on site. The focus groups ended with the question: ‘To
ture of the ECE learning environment cannot be ignored what extent did the clinical exposure improve your medi-
[20, 33]. Nonetheless, little has been done to explore how cal professionalism?’ Follow-up questions were asked to
different activities may influence students [26]. elicit more detailed descriptions of their experiences.
Liu et al. BMC Medical Education (2022) 22:435 Page 3 of 9

Participants Table 1 Participant demographics

Medical students who took the course during the spring Demographics N (%)
of 2019 were eligible for inclusion. To cover all 4 tracks,
1–2 medical students from each track were invited Gender
to participate in each focus group. Participants were Male 9 (41%)
selected by convenience sampling and snowball sam- Female 13 (59%)
pling. Six focus groups were held with 3–5 students in Grade
each group, for a total of 22 participants. First year 19 (86%)
Second year 3 (14%)
Module
Data analysis A: Nursing station 2 (9%)
Audio files from each focus group were transcribed ver- B: Dementia ward 8 (36%)
batim. Data were then analyzed using grounded theory, C: ICU 4 (19%)
including inductive and deductive open coding [50]. The D: Community 8 (36%)
initial deductive analysis was coded independently by
two researchers (CIL and YCW) based on the primary
codes and aggregate dimensions developed by Chiu et al.
[8]. All coders were required to prepare definitions and 8 chose Module B (dementia ward), 4 were in Module C
theories of medical professionalism before analyzing (ICU), and 8 participated in Module D (community). All
data. Coders initially formulated first-order codes that of the participants were 19–22 years old.
fit the original template, then proceed with inductive
coding when new first-order codes emerged. New codes
were reallocated through axial coding to new categories Theoretical dimensions of medical professionalism
and dimensions. When there was a disagreement, a third This study deduced 10 categories of responses based on
investigator (CHC) was invited to discuss the codes and the 5 major dimensions of medical professionalism as
categories, and form a consensus to ensure that inter- defined by Chiu et al. [8], in addition to 8 sub-dimensions
rater reliability exceeded 0.8. Lastly, reciprocal checking on participant attitudes and 2 sub-dimensions on per-
was utilized to confirm that all first-order codes, cat- sonal well-being. Associations between the three major
egories, and dimensions were allocated correctly. The dimensions are shown in Fig. 1.
original template included 5 major dimensions and 14 The 5 dimensions of medical professionalism include
categories. After coding, two more major dimensions medical knowledge and clinical skills (including con-
on personal factors emerged in addition to the 5 major tinuous learning, professional identity, and professional
dimensions on medical professionalism, as well as 10 cat- reputation), interpersonal skill with patients (including
egories and 34 first-order codes. compassion and communication), teamwork (includ-
ing coordination and cooperation), public health duties
(including health advocacy), and protection of patient
Ethical approval
rights (including information-sharing and self-determi-
This study was approved by the TMU-Joint Institu- nation, freedom to choose, and considering patients’ best
tional Review (No. N201609020). The work was carried interests). As all categories were deduced from the focus
out in accordance with the Declaration of Helsinki. Stu- group transcripts and therefore differ slightly from exist-
dents included in the study gave their oral and written ing definitions of medical professionalism [8], the catego-
informed consent. There was no potential harm to par- ries discussed in the focus groups are detailed in Table 2.
ticipants, and anonymity was maintained. All data and Two new categories — attitude and well-being —
results are reported anonymously to ensure participant emerged as items distinct from yet convergent with med-
confidentiality. ical professionalism. ‘Attitude’ covers student patience
and congeniality, scrutiny, ingenuity, and emotional sta-
Results bility. ‘Well-being’ covers the mental health and over-
Descriptive statistics all health/well-being of students. These two dimensions
A total of 22 students participated in the focus groups. serve as the foundation on top of which medical profes-
Complete demographics and descriptive statistics are sionalism may be built, and comprise the lessons par-
shown in Table 1. Of the participants, 41% (n = 9) were ticipants learned from their clinical exposure. The new
male and 86.4% (n = 19) were second-year medical stu- categories are described below in detail, including focus
dents. Two participated in Module A (nursing station), group quotations.
Liu et al. BMC Medical Education (2022) 22:435 Page 4 of 9

Fig. 1 Dimensions of medical professionalism, predicated on student well-being and attitudes toward early clinical exposure

Table 2 Self-reported levels of medical professionalism before/after ECE by theoretical category

Aggregate theoretical dimension Theoretical category Module A Module B Module C Module D

Medical knowledge & clinical skills Continuous learning 2/2 2/2

Professional identity 1/1 1/1 1/1
Professional reputation 2/2 1/1
Interpersonal skill with patients Compassion 1/1 2/3 1/1
Equity
Integrity
Communication skills 3/4 2/4 4/4
Teamwork Coordination & cooperation 0/1 0/1 1/2
Knowledge-sharing
Public health duties Health advocacy 0/2
Infection control
Protection of patient rights Information-sharing & self-determination 1/1
Confidentiality & dignity
Freedom to choose 1/1
Best interest of patients 0/2 0/1
Attitudes Patience 0/2 2/2
Congeniality 0/1
Scrutiny 1/2 1/1
Ingenuity 0/1
Emotional stability 1/2
Well-being Health/mental health 1/2 1/1 2/2

Compassion ‘Medical care personnel must have the ability to

Participants remarked on the importance of feeling be compassionate to others’ grief. If you don’t know
another’s sorrow and standing in patients’ shoes as a how difficult they have it, you can’t face them with
basic quality necessary for interacting with patients and the appropriate attitude when they are emotional.
their families. If you just look at their anger and don’t under-
Liu et al. BMC Medical Education (2022) 22:435 Page 5 of 9

stand their grief, you can’t sympathize with them.’ care that not only offers medical comfort, but also spe-
(Case #E-3). cialized facilities, and economic and social support.
‘In addition to solving clinical problems, clinicians
should provide comfort to patients. That means not
Communication skills
only dealing with pain and disease, but also helping
Participants reported learning to enhance their com-
improve their environment and access to economic
munication skills by fully comprehending a patient’s
support.’ (Case #A-3).
condition before approaching them and their family.
The ability to comprehend and interpret lab results and
recovery progress are critical to mutual understanding Patience and congeniality
between physicians and patients. Participants in Module B said that patience was essen-
‘They [clinicians] mentioned that in doctor-patient tial to being a good physician after visiting a dementia
communication, clinicians should summarize infor- ward and observing how a neurologist interviewed his
mation rather than giving disorganized medical patients.
information. I feel that medical staff should commu- ‘The clinician remained calm and patient when the
nicate from the perspective of the family, rather than patient repeated a persecutory delusion that her
from the perspective of an expert.’ (Case #A-3). caregiver was going to poison her.’ (Case #E-2).
Others cited congeniality as an important quality after
Coordination and cooperation shadowing attending physicians doing rounds.
Participants reported understanding the importance ‘The clinicians knew details about their patients.
of teamwork after interviewing nurses. They also real- They could point out what their patients remem-
ized the mutual respect that nurses expect to have with
ber or forget. It made me realize that clinicians are
physicians.
very responsible. They really care for every patient.’
‘I’ll never forget the nurse talking about cooperation (Case #A-2).
with doctors, and how families deal with nurses. I
think that nurses play an important role in medi-
cal work. They execute key aspects of patient care.’ Scrutiny
(Case #A-1). One participant in Module B noted the design of the
dementia ward, remarking that the touches of nostalgia
could benefit patients with anterograde amnesia. He also
‘They [nurses] have to put up with families and
highlighted the importance of empathic thinking.
patients, some of whom respect them, but some
don’t. I found that clinicians should not order the ‘The nostalgic design of the dementia ward was cute,
nurses around.’ (Case #A-1). like the red brick wall. After the course, I learned
that design can make patients feel more comfort-
able.’ (Case #A-3).
Health advocacy
Participants in Module B (dementia ward) reflected on ‘Overall, I believe that clinicians should always think
their responsibility to promote public health through about reasons and details. In the medical field, there
discussion of how the neighborhood near the hospital are reasons behind certain designs.’ (Case #A-3).
has managed to reduce traffic accidents. Some of them
even mentioned their support for promoting disease
prevention. Ingenuity
A clinician’s encouragement to think outside the box and
‘If we could reduce traffic accidents, in a way, we are
learn to stand in their patients’ shoes led one participant
saving people. I thought that saving people was the
to remark on how innovative thinking that centers the
same as saving their lives, but if we can prevent them
patient is essential for physicians.
from getting hurt, it also saves them.’ (Case #B-1).
‘Teachers encouraged us to think about what we can
do for our patients. Before the exposure, we only
Patients’ best interests learned in the classroom, but the teacher encour-
From visiting a dementia ward and the surrounding com- aged us to innovate and think outside the box.’
munity, Module B participants reported learning holistic (Case #A-2).
Liu et al. BMC Medical Education (2022) 22:435 Page 6 of 9

Emotional stability dimensions of attitude and well-being identified after

After interviewing patients’ families, participants intervention (Table 2). Before ECE, ‘medical knowledge
reported the importance of managing their emotions and and clinical skills’ and ‘communication skills’ were the
remaining neutral, regardless of a patient’s condition. most frequently mentioned sub-dimensions, while ‘team-
work,’ ‘public health,’ and ‘protection of patients’ rights’
‘Clinicians should practice to make sure their clin-
were rarely mentioned. After ECE, about 59% of partici-
ical work isn’t affected by emotion. That means
pants said they redefined their understanding of medi-
you can’t always be sad in your everyday work.’
cal professionalism. About 13.6% changed their attitude
(Case #E-3).
to embrace ‘communication skills,’ while another 13.6%
added ‘protection of patients’ rights’ to their definition.
‘Resilience. A doctor should be resilient.’ (Case #D-1).
Moreover, other emergent dimensions, such as thought-
fulness, patience, and personal well-being, were deuced
Well‑being after ECE. Figure 2 shows changes in participants’ rec-
Through interviews with clinicians, participants noticed ognition of medical professionalism before and after the
the importance of balancing one’s own health with intervention.
patient care. Further investigation of differences among the four
modules reveals that participants of Modules B, C, and D
‘The clinician emphasized the importance of relaxa-
supplied more insights on medical professionalism than
tion. Even when you are on duty, you should know
those who chose Module A. This might be related to the
how to relax. You can’t solve any problems when
design of these modules, as they incorporated intensive
you’re exhausted.’ (Case #D-2).
interaction between participants, medical staff, and third
parties such as patients, patients’ families, and commu-
‘Stress management. Well-being.’ (Case #E-3). nity residents, as opposed to only interaction with medi-
cal staff. Learning from direct encounters with patients
ECE effects and their families inspired participants to enhance their
Participant responses from before and after ECE were medical professionalism more than those who only inter-
organized and tallied according to the 5 sub-dimensions acted with medical staff. Designers of ECE interventions
of medical professionalism, as well as the additional should take this discrepancy into account.

Fig. 2 Mentions of physician qualities and expectations before and after intervention
Liu et al. BMC Medical Education (2022) 22:435 Page 7 of 9

Discussion As in previous studies [16, 27, 28, 39], this study proved
Before ECE intervention, most of the participants that ECE helps medical students cultivate their skills
assumed that medical professionalism was limited to and professionalism. However, not all of the partici-
medical knowledge and communication skills. After the pants believed that the intervention helped further their
course, most participants added to this definition respon- skill as medical professionals. Half of the participants
sibility to promote public health and protection of patient reported having an unsatisfactory experience, while none
rights. reported that ECE improved their motivation to perform
Unlike our previous survey [8], this study reflects Tai- well academically. This result is inconsistent with previ-
wanese medical students’ personal understanding of ous studies [19, 20, 23, 27, 29]. Since there are few stud-
medical professionalism. Before ECE, participants in 3 ies exploring the impact of ECE on professionalism, it is
of the 4 modules viewed medical knowledge and clini- hard to compare this finding.
cal skills as core components of medical professionalism. As each module included many different activities,
This finding could be attributed to the education system different elements may have affected participants in dif-
in Taiwan and extreme emphasis on performing well on ferent ways. For example, visitors to the dementia ward
knowledge tests in high school. Since Asian cultures gen- observed interviews between neurologists and patients,
erally emphasize academic competitiveness, humanities a brief introduction to a clinician, and the design of the
or communication skills are often ignored. ward, and were invited to ask questions of clinicians. All
Secondly, personality traits should be considered while of these elements may have separate effects on students’
developing ECE activities. Participants reported different awareness of professionalism, requiring further research
takeaways from the same courses, for instance, one stu- to clarify their actual effects. Motivation and personali-
dent after visiting a dementia ward noted the importance ties of the participants also appeared to have significant
of considering patients’ best interests, while another bearing on learning outcomes, requiring more qualitative
keyed in on patience as a quality central to being a good research to identify interactions between these factors.
clinician. The reason why ECE could influence students As opposed to the definitions of medical profession-
in such different ways could be attributed to their indi- alism proposed by Cruss [7], Castellani and Hafferty
vidual personalities. The diversity of activities in each of [52], and the Accreditation Council for Graduate Medi-
the four modules may have also influenced the partici- cal Education (ACGME) [53], which focus on Western
pants’ awareness of different facets of professionalism. culture contexts, the framework in this study was cho-
ECE is therefore a remarkably efficient and personal way sen because it reflects Taiwanese cultural values toward
of cultivating professionalism, and should be considered medicine [8]. This study therefore excludes certain cat-
by course designers. egories from the five dimensions and deduces two addi-
The four separate modules also triggered certain ways tional categories, attitudes and well-being, that support
of understanding medical professionalism. In Module A medical professionalism. Missing categories might imply
for example, participants noticed ‘teamwork’ and ‘well- that participants did not identify them when reflecting
being,’ but did not mention ‘communication skills’ and on their course. Moreover, the emergence of well-being
‘protection of patient right.’ This might be explained by as a foundational element of professionalism might be
the limited observation time and range of interests rep- explained by a rising awareness of personal wellness
resented through interviews with physicians. Gibson’s among younger generations.
dimensional framework provides a closer look at how
role modeling functioned in ECE activities [51]. Role
modeling seemed to be a neutral way to shape medical Limitations
professionalism, but among those in Module B, there The study has three major limitations. Firstly, due to time
was no mention of ‘duty toward public health,’ although limits, each module included only 4–6 h of clinical expo-
they did mention ‘medical knowledge and clinical skills’ sure and 8–10 h of in-depth discussion with instructors.
and ‘well-being.’ In Module C, participants covered most Cultivating professionalism is not a one-time interven-
dimensions, but not ‘teamwork,’ ‘duty toward public tion, but a long-term process. We therefore look forward
health,’ and ‘protection of patient rights,’ while in Module to conducting a follow-up study investigating longer-
D, ‘well-being’ was not covered. Based on these results, term changes among the participants. Secondly, we did
service learning in a dementia ward (Module B), discus- not address instructor skill and its potential effect on out-
sions of ethics in the ICU (Module C), and participating comes. Thirdly, there were a few topics that emerged in
in a community health program (Module D) were most the focus groups that did not fit into our original frame-
effective at shaping a comprehensive understanding of work [8]. Lastly, this result may only be applied to observ-
medical professionalism. able attributes of medical professionalism.
Liu et al. BMC Medical Education (2022) 22:435 Page 8 of 9

Conclusion 3. Birden H, et al. Teaching professionalism in medical education: a Best

Evidence Medical Education (BEME) systematic review. BEME Guide No
ECE helps to form and cultivate medical professional- 25 Med Teach. 2013;35(7):e1252-66.
ism in the early stages of medical education, although the 4. Zare S, Yamani N, Changiz T. How to develop an undergraduate medical
relationship between participants’ personalities, motiva- professionalism curriculum: Experts’ perception and suggestion. J Adv
Med Educ Prof. 2019;7(4):183–90.
tion, and clinical elements should be taken into account 5. Huang CD, et al. How does narrative medicine impact medical trainees’
in further research. learning of professionalism? A qualitative study. BMC Med Educ.
2021;21(1):391.
6. Bashir A, McTaggart IJ. Importance of faculty role modelling for teach‑
Abbreviations ing professionalism to medical students: individual versus institutional
ECE: Early clinical exposure; ICU: Intensive care unit. responsibility. J Taibah Univ Med Sci. 2022;17(1):112–9.
7. Cruess RL, et al. Reframing medical education to support professional
Acknowledgements identity formation. Acad Med. 2014;89(11):1446–51.
We would like to take this opportunity to express our sincere appreciation to 8. Chiu C-H, et al. A professionalism survey of medical students in Taiwan. J
all the participants. We also appreciate the grants from the Ministry of Ministry Exp Clin Med. 2010;2(1):35–42.
of Science and Technology, and the editing assistance from Miss Kayleigh 9. Chiu C, Pan S, Lin Y. How plastic surgeons value professionalism: using q
Madjar. methodology to explore the prioritization of professionalism. Aesthetic
Surg J. 2019;39(12):1412–22.
Authors’ contributions 10. Brody H, Doukas D. Professionalism: a framework to guide medical educa‑
CIL, KPT, and CHC designed and conceived of the study. CIL, KPT, YCW, and tion. Med Educ. 2014;48(10):980–7.
CHC carried out the study, and prepared the manuscript. CIL, YCW, and CHC 11. Branch WT Jr. Supporting the moral development of medical students. J
analyzed qualitative data. CHC responded to editorial and reviewer comments. Gen Intern Med. 2000;15(7):503–8.
All authors read and approved the final manuscript. 12. Irby DM, Hamstra SJ. Parting the clouds: three professionalism frame‑
works in medical education. Acad Med. 2016;91(12):1606–11.
Funding 13. Tsai M. Early exposure to global health raises self-awareness of medical
This study was supported by Ministry of Science and Technology, which had novices on professionalism. J Med Educ. 2019;23(1):42–52.
no role in the study design, data collection, analysis, and interpretation of data, 14. Chiu C, Wu J, Chen C. Why do young physicians make a “detour” to
writing of the report, or decision to submit the article for publication. Grant aesthetic clinics? An exploration of professional identity among young
No. were MOST 108–2813-C-038–012-H and MOST109-2511-H-038–006-MY2. physicians who changed career paths. J Med Educ. 2019;23(4):207–17.
There was no additional external funding. 15. Bryan CS, Babelay AM. Building character: a model for reflective practice.
Acad Med. 2009;84(9):1283–8.
Availability of data and materials 16. Verma M. Early clinical exposure: New paradigm in Medical and Dental
No data have been submitted to any open-access databases. All data sup‑ Education. Contemp Clin Dent. 2016;7(3):287–8.
porting the study are presented in the manuscript or are available from 17. Dornan T. Osler, Flexner, apprenticeship and “the new medical education.”
corresponding author upon reasonable request. J R Soc Med. 2005;98(3):91–5.
18. Souza R, Sansevero A. Introducing early clinical experience in the cur‑
riculum. 2015. p. 144–56.
Declarations 19. Sathishkumar S, et al. Attitude of medical students towards early clinical
exposure in learning endocrine physiology. BMC Med Educ. 2007;7:30.
Ethics approval and consent to participate 20. Tang KP, et al. Correlation between early clinical exposure environment,
The Taipei Medical University-Joint Institutional Review approved the study attitudes toward basic medicine, and medical students’ basic science
protocol (No. N201609020). The work was carried out in accordance with the learning performance. BMC Med Educ. 2019;19(1):183.
Declaration of Helsinki. Students included in the study gave their oral and 21. Kar M, et al. Early clinical exposure as a learning tool to teach neuroanat‑
written informed consent. There was no potential harm to participants, and omy for first year MBBS students. Int J Appl Basic Med Res. 2017;7(Suppl
anonymity was maintained. All data and results are reported anonymously to 1):S38–41.
ensure participant confidentiality. 22. Eika B, et al. Early clinical exposure–an instant success. The new medical
curriculum at the University of Aarhus. Ugeskrift Laeger. 2001;163:3626–9.
Consent for publication 23. Gupta K, Gill G, Mahajan R. Introduction and Implementation of early
Not applicable. clinical exposure in undergraduate medical training to enhance learning.
Int J Appl Basic Med Res. 2020;10(3):205–9.
Competing interests 24. Khabaz Mafinejad M, et al. Medical students’ attitudes towards early clini‑
The authors declare that they have no competing interests. cal exposure in Iran. Int J Med Educ. 2016;7:195–9.
25. Hopayian K, Howe A, Dagley V. A survey of UK medical schools’ arrange‑
Author details ments for early patient contact. Med Teach. 2007;29(8):806–13.
1
Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan. 2 Department 26. Abramovitch H, et al. A tale of two exposures: a comparison of two
of Early Childhood and Family Education, College of Education, National Taipei approaches to early clinical exposure. Educ Health (Abingdon).
University of Education, Taipei, Taiwan. 3 Shuang Ho Hospital, Taipei Medical 2002;15(3):386–90.
University, New Taipei City, Taiwan. 4 School of Health Care Administration, 27. Dornan T, Bundy C. What can experience add to early medical education?
Taipei Medical University, Taipei, Taiwan. Consensus survey. BMJ. 2004;329(7470):834.
28. Lie D, et al. What do medical students learn from early clinical experi‑
Received: 24 January 2022 Accepted: 27 May 2022 ences (ECE)? Med Teach. 2006;28(5):479–82.
29. Rani MA, Sharma KS, Koirala S. What do students say about the early clini‑
cal exposure at B.P. Koirala Institute of Health Sciences, Nepal? Med Teach.
2002;24(6):652–4.
30. Wilkinson T, Gower S, Sainsbury R. The earlier, the better: The effect of
References early community contact on the attitudes of medical students to older
1. Basak O, et al. Early clinical exposure in medical curricula across Europe: people. Med Educ. 2002;36:540–2.
an overview. Eur J Gen Pract. 2009;15(1):4–10. 31. Hannay D, Mitchell C, Chung MC. The development and evaluation of
2. Wear D, Castellani B. The development of professionalism: curriculum a community attachment scheme for first-year medical students. Med
matters. Acad Med. 2000;75:602–11. Teach. 2003;25(2):161–6.
Liu et al. BMC Medical Education (2022) 22:435 Page 9 of 9

32. Diemers AD, et al. Students’ perceptions of early patient encounters in

a PBL curriculum: a first evaluation of the Maastricht experience. Med
Teach. 2007;29(2–3):135–42.
33. Ottenheijm RP, et al. Early student-patient contacts in general practice: an
approach based on educational principles. Med Teach. 2008;30(8):802–8.
34. Miettola J, Mantyselka P, Vaskilampi T. Doctor-patient interaction in Finn‑
ish primary health care as perceived by first year medical students. BMC
Med Educ. 2005;5:34.
35. Howe A, et al. Patient contact in the first year of basic medical training–
feasible, educational, acceptable? Med Teach. 2007;29(2–3):237–45.
36. Vieira JE, do PatrocínioTenórioNunes M, de Arruda Martins M. Directing
student response to early patient contact by questionnaire. Med Educ.
2003;37(2):119–25.
37. Haffling AC, Håkansson A, Hagander B. Early patient contact in primary
care: a new challenge. Med Educ. 2001;35(9):901–8.
38. Forster DP, et al. The family study: a model for integrating the indi‑
vidual and community perspective in medical education. Med Educ.
1992;26(2):110–5.
39. Dornan T, et al. How can experience in clinical and community settings
contribute to early medical education? A BEME systematic review. Med
Teach. 2006;28(1):3–18.
40. Littlewood S, et al. Early practical experience and the social responsive‑
ness of clinical education: systematic review. BMJ. 2005;331(7513):387–91.
41. McLean M. Sometimes we do get it right! Early clinical contact is a
rewarding experience. Educ Health (Abingdon). 2004;17(1):42–52.
42. Shibli-Rahhal A, et al. A practical approach to integrating communication
skills and early clinical experience into the preclinical medical school cur‑
riculum. Med Sci Educ. 2019;29(4):947–57.
43. Chen H, et al. Students’ goal orientations, perceptions of early clinical
experiences and learning outcomes. Med Educ. 2016;50:203–13.
44. Duban S, et al. Teaching clinical skills to pre-clinical medical students:
integration with basic science learning. Med Educ. 1982;16(4):183–7.
45. Hellquist G, et al. Early professional contact supports professional devel‑
opment of medical students. EPC–a new course in medical education in
Gothenburg. Lakartidningen. 2005;102(38):2646-8-2650–1.
46. Mann MP. A Light at the End of the Tunnel: The Impact of Early Clinical
Experiences on Medical Students. 1994.
47. Rooks L, Watson RT, Harris JO. A primary care preceptorship for first-year
medical students coordinated by an Area Health Education Center
program: a six-year review. Acad Med. 2001;76(5):489–92.
48. Woolliscroft JO, Schwenk TL. Teaching and learning in the ambulatory
setting. Acad Med. 1989;64(11):644–8.
49. Ramachandran K, et al. Early clinical exposure through innovative interac‑
tive clinical anatomy lectures. Natl Med J India. 2015;28(6):291–4.
50. Watling CJ, Lingard L. Grounded theory in medical education research:
AMEE Guide No 70. Medical Teach. 2012;34(10):850–61.
51. Gibson DE. Role models in career development: new directions for theory
and research. J Vocat Behav. 2004;65(1):134–56.
52. Castellani B, Hafferty FW. The complexities of medical professionalism. In:
Professionalism in medicine. Springer; 2006. p. 3–23.
53. ACGME. The Accreditation Council for Graduate Medical Education. 2022.

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