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ORIGINAL ARTICLE
Year : 2022  |  Volume : 31  |  Issue : 1  |  Page : 141-150  Table of Contents     

Students' perceptions on newly designed foundation course at MBBS entry level: A mixed-method study


1 Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
2 Department of Microbiology, Christian Medical College, Ludhiana, Punjab, India

Date of Submission10-Apr-2020
Date of Decision08-Jun-2021
Date of Acceptance07-Sep-2021
Date of Web Publication21-Dec-2021

Correspondence Address:
Dr. Kavita R Bhatnagar
Department of Ophthalmology, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ipj.ipj_67_20

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   Abstract 

Background: Selection of students to medical colleges is based on merit of candidate at written entrance examination which does not take care of nonscholastic abilities of the students. Medicine is a profession that requires not only mastery of large body of knowledge and clinical skills but also high standards of professionalism and appropriate attitudes. Methodology: A 1-month long foundation course was conducted for the fresh students admitted to MBBS course at Andaman and Nicobar Islands Institute of Medical Sciences, Port Blair, India. Seventy-four students had joined the course. The course was planned, arranged, and executed by the department of Medical Education Unit. It included six modules. Retrospective pre- and postevaluation was done for knowledge, skill, and attitude. Wilcoxon signed-rank test was used for all pair-wise comparisons. Participants also completed a questionnaire (Likert scale and some open-ended items) about educational quality of sessions and utility of the course. Descriptive statistics and qualitative methods were used for data analysis. Results and Conclusion: Response rate was 100%. Students perceived foundation course as an excellent opportunity to acquire basic knowledge, attitude, and skills required for subsequent phases in MBBS course. This Foundation Course enhanced their orientation to the curriculum and campus, boosted confidence to cope up with the challenging syllabus, helped them develop time and stress management skills, and also sensitized them to achieve the highest standards of morale required to ensure ethical practice.

Keywords: Competency-based curriculum, foundation course, Indian medical graduates, student perception, teaching learning


How to cite this article:
Bhatnagar KR, Oberoi A. Students' perceptions on newly designed foundation course at MBBS entry level: A mixed-method study. Ind Psychiatry J 2022;31:141-50

How to cite this URL:
Bhatnagar KR, Oberoi A. Students' perceptions on newly designed foundation course at MBBS entry level: A mixed-method study. Ind Psychiatry J [serial online] 2022 [cited 2022 Nov 29];31:141-50. Available from: https://www.industrialpsychiatry.org/text.asp?2022/31/1/141/333000



The selection of the students to medical colleges is based on merit of the candidate at a written qualifying entrance examination.[1] The selection criteria do not take care of nonscholastic abilities of the students. Many students who pursued rote learning in secondary and higher secondary education may find it difficult to cope up with different educational environment in medical college. Furthermore, student from diverse cultural backgrounds may find difficulties in adapting to new environment. Medicine is a new profession that requires not only a large body of knowledge base and clinical skills but also high standards of professionalism and attitudes. It is also important to train the undergraduate students in techniques of learning which will motivate them to develop self-directed learning.[2]

The regulatory body governing medical education in India, National Medical Commission (NMC) erstwhile Medical Council of India (MCI), has rolled out Competency-Based Curriculum for Indian Medical Graduates (IMGs) from the batch of 2019 for Bachelor of Medicine and Bachelor of Surgery program (MBBS). The overall goal of undergraduate medical education program is to create an IMG possessing requisite knowledge, skills, attitudes, values, and responsiveness, so that he or she may function appropriately and effectively as a physician of the first contact of the community while being globally relevant. To effectively fulfill the above-mentioned roles, the IMG must obtain a set of competencies at the time of graduation. To ensure that training is in alignment with the goals and competencies, a structured Foundation Course at MBBS entry level will go a long way. A foundation course aims to help students adjust to a new environment and a vast curriculum, and to orient them to Medical profession and physician's role in society, overview of the MBBS program: learning strategies, examinations, etc., health needs of the country: policies, organization, alternate health systems in country, medical ethics, attitude, and professionalism, health-care system and its delivery, National health priorities and policies, patient safety and biohazard safety, principles of family practice, IMG document of MCI, orientation to the institute: rules, facilities, faculty, library, hospital, national health scenarios, health economics, sociology and demographics, environmental issues, and community orientation. It also aims to enable students to acquire skills in language training, interpersonal relationship, communication, learning skills including self-directed learning, time management, stress management, use of information technology and to train them to provide first aid, basic life support, and community visits/clinical visits.[3],[4]

The foundation program also provides opportunity for medical students on the development of behavioral competency, familiarize them to campus environment, to develop camaraderie among students, and discover their talents by engaging in sports, debates, cultural, and other co-curricular activities.


   Methodology Top


Keeping NMC (erstwhile MCI) guidelines as basic framework, a 1-month long “Foundation Course” for the 74 fresh students admitted to MBBS course was conducted. Institutional Ethics committee approval was obtained and the work was carried out according to the Declaration of Helsinki.

The course was planned, arranged, and executed by the Department of Medical Education Unit (MEU) in association with the preclinical departments of Andaman Nicobar Islands Institute of Medical Sciences, Port Blair. Foundation Course Committee was constituted by the Dean and Director as the Chairperson and MEU Coordinator as the master lead. Individual sessions were designed using mixed-method approach and presented before the core group. Suggestions were taken and necessary modifications were made. The emphasis was on interactive sessions with the use of group activities, use of videos, movie clips, use of mannequins, and hands-on training in small groups with minimum use of didactic lectures and jargon. The course was planned before the beginning of regular classes.

The foundation course had six sections

Orientation, skill module, field visit to community health center, professional development including ethics, sports and extracurricular activities, computer skills, and language program. A timetable was prepared for the same. Sessions included in foundation course are listed below [Table 1].
Table 1: Foundation course- List of topics

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The program began with the inaugural address by the Director which focused on vision, mission, and objectives of medical education to be followed at the institute and also the national level. To reduce the students' apprehension, a formal faculty introduction was held. This was followed by formal student introduction where pairs of students were asked to introduce each other. The first session was on group dynamics which started with an outdoor group activity followed by power point presentation and QA session. Ice-breaking and session on group dynamics helped students open up and be interactive during subsequent sessions. Some of the sessions were in the form of interactive lectures and video demonstrations, short movies in large group while others were in the form of small group sessions, role-plays by the faculty as well as students, hands on training on mannequins, cadaver and other tissue handling, and group tasks in groups of 7–8 students. Visits to the hospital, library, and community health centers were undertaken in small groups of 16–17 students. Students were encouraged to participate in extracurricular activities including sports, yoga sessions, cultural activities, etc., The course ended with fresher's party where all 74 students participated in “Ramp Walk” along with participating faculty and other cultural activities. Photo collage of various activities during foundation course is a representation of the same [Figure 1].
Figure 1: Representative photo-collage of excerpts from the foundation course

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Collection of feedback

At the end of the day, all students and participating teachers were given a specially designed questionnaire to assess the feedback in terms of the teacher-related factors, the peer-related factors, the impact of teaching methodology, the impact of the foundation course, and the suggestions. Validation of all questionnaires was done through peer review during our listserve discussions of FAIMER CMCL FRI and modifications were done accordingly. The students were also allowed to present their reflections in form of poetry, story, essays, powerpoint presentations with pictures and videos. The qualitative analysis of the data was done for the open-ended questions. The following problems were posed by the researchers for all students to answer to assess their perception of educational quality of the foundation course:

  1. Which behaviors or characteristics of teacher-facilitated or hindered learning?
  2. Which behaviors or characteristics of your peers facilitated or hindered learning?
  3. Which teaching-learning methods facilitated/hindered learning?
  4. How will this foundation course help you to cope with challenging medical course?
  5. What would have been done better? Your suggestion please.


A similar questionnaire was designed for teachers as well. Following questions were posed:

  1. How do you think these sessions were beneficial for the students?
  2. Which methodology of teaching was adapted?
  3. How would you grade your experience with this methodology of teaching in a scale of 0–5 with respect to students enthusiasm and learning?
  4. Overall experience being a part of this project?
  5. Any suggestions?


Data analysis

Numerical data was entered in Microsoft Excel sheets and descriptive analysis was done using IBM SPSS Statistics 20 SPSS software (College station, Texas, USA). Mean scores and standard deviation were calculated for student responses on questionnaire meant to assess prior knowledge, gain in knowledge, and knowledge essential for medical profession. A 3-point Likert scale was used for this purpose (1 = not at all, 2 = to some extent, 3 = to great extent). Nonparametric test “Wilcoxon signed-rank test” was used for all pair-wise comparisons and to disprove null hypothesis. Results were suitably tabulated and presented in the form of graphs. A P < 0.05 was taken as significant. Responses on close-ended questionnaire to assess student perceptions of educational quality and utility of the course were summarized in the form of percentage of responses on a 5-point Likert scale (Strongly disagree = 1, disagree = 2, undecided = 3, agree = 4, strongly agree = 5). Cronbach's alpha as a measure of internal consistency was calculated. Student responses to open text type questions on educational quality and utility of the course were entered in MS word. Code or label words were found in the transcript (open coding), and then, themes were created by grouping these codes or labels given to words or phrases (axial coding). A separate master list of all the codes was prepared for all open-ended questions and percentage (number) of comments was calculated for each code. Results were presented in tabular form with sample student responses to maintain originality. Excerpts from student reflections were included verbatim.


   Outputs And Results Top


A total of 74 MBBS students were enrolled and completed the project. Eight were excluded from the analysis as their forms were found to be incomplete. The group included 55 girls and 19 boys. All were from English medium schools and single national board but from culturally diverse and different socioeconomic status. Response rate was 100%.

Quantitative analysis

The mean scores of student perceptions of prior knowledge ranged between 1.27 ± 0.482 and 1.83 ± 0.543, for knowledge gain, it ranged between 2.26 ± 0.535 and 2.73 ± 0.482. The gain in knowledge was statistically significant with P < 0.0001 for all the sessions calculated by Wilcoxon signed-rank test for paired comparisons. Mean scores for knowledge essential for medical profession ranged between 2.42 ± 0.658 and 2.97 ± 0.173 (maximum permissible score 3). This is an evidence that all students felt that all sessions included were essential to study medicine effectively [Table 2].
Table 2: Mean scores±standard deviation of student's perceptions of prior knowledge, gain in knowledge, and necessity of foundation course for medical profession

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Majority of students appreciated the importance of all the topics to great extent minimum 40 (for national health scenarios) to maximum 64 (for medical ethics and professionalism). Sociology and demographics, research and short-term studentship projects, computer learning, environmental issues which were thought to be relatively less important (to great extent by ≤37 students and to some extent by 22–28 students) [Table 3].
Table 3: Percentage responses close-ended questionnaire course educational quality and utility (strongly disagree=1, disagree=2, undecided=3, agree=4, strongly agree=5)

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Mean pre- and postscores for skill ranged from 1.18 to 2.5 and from 2.97 to 3.38, respectively (maximum score = 4). Wilcoxon signed-rank test for all pair-wise comparisons shows statistically significant improvement in skills with P < 0.0001 for all sessions. 97.90% students said that they agreed to what we labeled as unethical and unprofessional behavior. The questionnaire had 59 items. It included items such as cheating in examination, proxy attendance, taking credit for someone else's work, doing assignments for other students, forging signatures, submitting the same work multiple times, coming late for class, plagiarism, reporting physical examination as normal when it was omitted, altering labels or slides in an examination, telling wrong concepts to fellow colleagues to avoid competition, personal excuses, sexual misconduct, asking lab attendant for spot diagnosis, asking residents help for diagnosis, making fun of patients, peers or teachers, being introduced as doctor to the patient, poor conditions of “white coats” and wearing them outside hospital/college campus, discuss with patients information beyond your knowledge to name a few.

Reliability statistics show Cronbach's alpha value of 0.676 in our study. We say that Cronbach's alpha is satisfactory if it is 0.7 and above, excellent if 0.9 and above. It is possible that the questions are measuring different constructs. There was >90% positive response to majority of the questions with <3.03% negative response to questions 1, 2, 3, 6, 7, and 8.

Qualitative analysis of student feedback

Qualitative data generated was collected, organized into codes, categories, and themes.

Analysis of data in the form of findings is presented in [Table 4] and [Table 5]. Percentages of comments and sample student responses are also included.
Table 4: Open-ended questionnaire responses categorized into common themes-I

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Table 5: Open-ended questionnaire responses categorized into common themes-II

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Themes generated from probe 1 were personal traits of teachers and teaching methods and styles. Personal traits of teachers which facilitated learning were encouraged student to interact (83.33%), friendly, humble, and approachable (81.81%), fairness (45.45%), knowledgeable and inspirational (45.45%) in that order. Teaching methods and styles which facilitated learning were interactivity (54.54%) and presentations with good illustrations and videos (53.03%). Factors which hindered learning was bias (37.87%) in the form of teachers paying more attention to single student or single student group, too lengthy sessions (18.18%) while majority wrote nothing hindered (62.12%). Themes generated from probe 2 were personal traits of peers. In that following codes were extracted, friendly, helpful nature of peers and unity (62.12%), interactive, attentive and focused (60.60%), facilitated learning which distracting/disturbing (42.42%), dominating/over participative (37.87%) hindered learning [Table 4].

The themes generated from probe 4. The themes were confidence building, orientation in preclinical subjects and MBBS course/curriculum, skills learning, time/stress management and fitness and what does it mean to be a doctor. The codes were confidence to cope with medical course (90.9%), familiarized with campus environment (68.18%), ice-breaking session (100%), developed team/group management skills (78.78%), physician's role and responsibilities to the society and community that she/he serves (78.78%), knowledge of medical ethics and professionalism (83.33%), commitment to life-long learning (68.18%) [Table 5].

Hundred percent (25/25) of the teachers too had a positive feedback about all the sessions included in foundation course. All the teachers were of the opinion that the session conducted by them was beneficial. Ninety-two percent (23/25) teachers were of opinion that the interactive teaching had a better response from the students. The methodologies with highest grades were those with interactive sessions such as skit plays (average 4.24/5), field trips (average 4/5), and debate (average 3.7/5). Six teachers suggested that although the project appeared to be extremely beneficial for the students, the time required for conduction of the same was utilized from the already tightly packed schedule of 1st year. This suggestion to include this curriculum before admission was also put forth by a couple of them.


   Discussion Top


Imparting students with sound medical knowledge and skills, developing behavioral and attitudinal skills to transform them into a dedicated health worker is one of the major responsibilities vested in a faculty of a medical college.[5] Reforms in the existing curriculum are necessary to enable them to achieve these goals.[6] The essence of this course was to provide a fertile ground for imparting the knowledge and skills required for completion of course. This interactive curriculum innovation program introduced with the objective of laying a foundation stone for transformation of the directionless enthusiastic young minds into a chef-d'oeuvre in the form of a dedicated medical practitioner of high morale was applauded by those benefitting from this program. Previous studies on the effectiveness of foundation course for the MBBS students have also found that medical students immensely benefited from it.[5],[6],[7],[8] This is very well reflected from the following excerpt taken from a students' reflection [Box 1].



The session began with the formal inaugural ceremony which was followed by the ice-breaking session. Ice-breaking session was an interactive one which helped the students interact with each other and showcase their personality.

  1. Ice-breaking session – The ice-breaking session was very interactive giving each and every student a platform to express themselves which was quite extravagant and humorous as well.


  2. The qualitative analysis of the data revealed that certain personality traits of teacher, behavior of teachers as well as teaching methodology play a significant role in learning process. This can be elicited from the following reflections of the students.

  3. Exposure to phenomenal learning methods–quite different from those being followed by us till now (an excellent help)
  4. Teachers were highly knowledgeable, motivational, and encouraging……Best part…encouraged to ask questions and given enough time to answer…


The reflections very well correlate with the characteristics of a good teacher mention by Baier et al.[6]

Methodology of teaching also plays a critical role in invoking interest in students, increasing attentiveness, effective delivery of the intricate knowledge, and the ultimate learning experience for students. From the classic age-old methods of background teaching to newer and more interactive methods including group discussions, video-based demonstrations, debates, skits, seminars, and symposiums by the students, the methodology of teaching has witnessed a drastic transformation. The various interactive sessions were very well appreciated by the students. The effectiveness of interactive teaching has also been demonstrated in previous studies.[7],[8]

Some of the interventions were especially appreciated by the students, who believed that these interventions created a significant impact on their young minds.

Some of these are as follows:

  1. “I still remember the rule of 5D's mentioned by Director, i.e., DEVOTION DEDICATION DETERMINATION DIGNITY DISCIPLINE and I have promised myself that I will follow this till my last breath”
  2. “The much-awaited moment in my life took place that day, which was when we all took the Hippocratic Oath wearing our white coats. After taking oath I personally felt that yes now the time has come to my responsibilities are waiting for me”
  3. “Knowing how we have evolved is much important especially when it comes to medical profession–a session on HISTORY OF MEDICINE and EVOLUTION OF MEDICAL KNOWLEDGE. (Believe me! It was keenly interesting and informative)”
  4. “Awesome ways of managing time and stress by meditating, exercising, avoiding procrastination, working in small intervals, habit to make to do–list, prioritizing the tasks and numerous other ways were taught”
  5. “The postlunch session had an interesting and relevant debate on the topic “technology is killing the art of learning” which was followed by few questions from the audience. The debate really enabled us to ponder our thoughts upon the use of technology in our medical studies.”


Knowledge about medical ethics and professionalism is a foundation stone in the formative process of a dedicated medical practitioner with high standards of morale. In the past, teaching medical ethics was limited to a couple of chapters in certain textbooks.[6] Knowledge and information that was gained was only through enthusiastic reading and observing the seniors.[9] What retained was usually the legal ethics with a negligible role of clinical and research ethics.[9] There was no uniformity in the code of conduct. Many a times the role models of such students were unable to stand by their words. This lead to a wide disparity in what was preached and practice.[10] Training of undergraduate students in medical ethics is one of the most desired changes in the reformation of curriculum. The sessions like cadavers as teachers were directed toward sensitizing the students the importance of these human resources of learning.[11]

The evolving trends of modern era demand a high standard of professional attitude in addition to the sound knowledge of the subject for the effective delivery of the health care.[12] These values of professionalism should be inculcated right from the beginning of their journey.[6] These values can be inculcated at the formative stage to nip in the bud of any developing unprofessional attitude. Various methods have been described to teach professionalism.[6],[12],[13],[14],[15],[16] In this foundation course, a special session was dedicated to the orientation of ethics and professionalism which was savored by them.

  1. This was a pretty much important day since it withheld something that cements a Doctor to his profession that is “medical ethics and professionalism.” The true foundation laying for new sprouting doctors was laid down. We were introduced to the life-like situation and work out a possible solution to the adverse circumstance: Without degrading the medical ethics and without disgracing true professionalism.
  2. “Trees do not deny their shades even to the people, who come to cut it down, HOSPITALITY and KINDNESS shown even to the enemies is the true charity.” This session was all about how to become a good doctor. Doctor should also have the personality of a “TREE.”


Time and stress management sessions are extremely important in helping the medical students to cope up with the overwhelming pressures of medical studies. These students may otherwise fall prey to these stressors.[17],[18] These sessions were cherished by many of them.

  1. “Awesome ways of managing time and stress by meditating, exercising, avoiding procrastination, working in small intervals, habit to make to do–list, prioritizing the tasks, and numerous other ways were taught.”


The students also suggested certain changes that can be included to increase the effectiveness of the program. Some of these were more time for relaxation, more emphasis on community-based education, and inclusion of student seminars.

The teachers also had a positive feedback about the project with a unanimous agreement on the beneficial impact of this project on the overall development of the students as doctors. Teachers perceived this as a platform to create responsible and disciplined medical practitioners.

Documented feedback will be incorporated in future sessions.

The overall success of this program can be evaluated from the impact that this project had on these young minds.

  1. “A journey of thousands miles start from a single step only.” We also had taken the first step for the long journey of 5 1\2 years in our life, through the very informational foundation course.
  2. “By the sea I find my focus……, Here is the space to be myself………, Commune with surf and sand and sky.”
  3. “All birds find shelter during the rain, but the eagle flies through above clouds. It is not the “problem” but the “attitude” which makes a difference!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.”



   Conclusion Top


Students perceived foundation course as an excellent opportunity to acquire basic knowledge, attitude, and skills required for subsequent phases in MBBS course. This foundation course enhanced their orientation to the curriculum and campus, boosted confidence to cope up with the challenging syllabus, helped them develop time and stress management skills, and also sensitized them to achieve the highest standards of morale required to ensure ethical practice.

This foundation course was successful in creating an impact on these young minds as reflected in Student's feedback and reflections revealed. In the student's words [Box 2], the foundation course has now become an integral part of training of undergraduate students.



Acknowledgments

I sincerely thank Dr. T Singh, Dr. Dinesh Badyal, and Dr. Peter from CMCL FAIMER Regional Institute, Ludhiana, for helping me with this Faimer project. My sincere thanks to faculty of ANIIMS, Port Blair, for their contribution. I am thankful to Dr. S L Jadhav, Professor, Community Medicine, DYPMC, Pune, for helping me with the statistical analysis. I sincerely thank my dear students who were very enthusiastic, interactive, and focused and were the biggest strength of this project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Medical Council of India. Regulations on Graduate Medical Education, 2012. New Delhi: Medical Council of India; 2012. p. 3-6. Available from: http://www.mci.org/tools/announcement/Revised_GME_2012.Pdf. [Last accessed on 2020 Jan 04].  Back to cited text no. 1
    
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Mahajan R, Aruldhas BW, Sharma M, Badyal DK, Singh T. Professionalism and ethics: A proposed curriculum for undergraduates. Int J Appl Basic Med Res 2016;6:157-63.  Back to cited text no. 16
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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