The attitudes and perceptions of medical students towards basic science subjects during their clinical years: A cross-sectional survey.

INTRODUCTION: In the conventional system of medical education, basic subjects are taught in the 1(st) year with least interdisciplinary interaction. The objective of this study was to explore the students' perception about content, need and application of basic science subjects during the clinical years of their medical education.
MATERIALS AND METHODS: A total of 300 questionnaires were distributed among students randomly after taking their written consent for participation in the study. About 265 completely filled questionnaires were received back and the response was analyzed.
RESULTS: Students identified anatomy as the subject with overloaded syllabus (75.4%) and also with maximum clinical application with 50.1% of them considering it the most important basic subject. Students were satisfied with the practical integration of subjects to impart clinical skills, but considered problem based learning a better method of teaching. According to 37%, 43.8% and 33.2% of respondents respectively; anatomy, biochemistry and physiology curriculum should only cover the general concepts to give the working knowledge of the subject. Approximately, 65% of the respondents were able to recall the knowledge of anatomy and physiology while biochemistry was retained by 40%.
CONCLUSIONS: Overall, the attitudes of students toward basic science subjects were positive. The learning experience for them can be improved significantly by better clinical integration of the subjects.

INTRODUCTION

Medical students build their clinical knowledge on the grounds of previously obtained basic knowledge.[1] There is a growing concern among medical educators that traditional programs of teaching medical students have not provided better outcomes of learning.[2] In the conventional system of medical education, basic subjects (anatomy, biochemistry and physiology) are taught in the 1st year of 4.5 years medical course with least interdisciplinary interaction. In most of the medical schools of India, it is mainly taught by means of didactic lectures, tutorials and practical classes. Such a system is teacher centered with minimal active participation from the students.[3] Many senior undergraduate students indicate informally that their memory of basic science medical courses is less than expected and the content of those courses did not seem relevant to their later clinical work or studies.[4] Moreover, the students become increasingly negative in their opinions about basic science courses as they progressed through their medical education.[5] These opinions are important as the purpose of education is defeated if the knowledge gained becomes inert and inaccessible.

This study was planned with the objective of exploring the students’ attitudes and perception about content, need and application of basic science subjects in the clinical years of their medical education.

MATERIALS AND METHODS

This cross-sectional study was conducted during the academic year 2012-2013 among the medical students of second to final professional and interns at a private medical college in Punjab. The college admits 100 students every year and as per the revised examination schedule of Medical Council of India, examinations are conducted in three phases after first professional examination. This is followed by 1 year compulsory rotational internship in all the clinical subjects.

Data was collected using an anonymous predesigned questionnaire. Pre-testing was conducted using a sample of 20 students who were asked to comment on the content and clarity of the questionnaire. Necessary modifications were made as per the feedback received. A total of 300 questionnaires were distributed among students randomly after taking their written consent for participation in this study. Out of these, 265 completely filled questionnaires were received back from the students. The questionnaire collected information on students’ academic year and their perceptions of the following characteristic of basic science courses: Syllabus overload, information recall, practical integration of knowledge, necessity of basic science subjects for clinical knowledge and application in clinical practice. All opinions were rated using a five-point Likert scale, which ranges from “strongly disagree” to “strongly agree.” All opinion levels were initially analyzed and those who responded as strongly agree or agree were merged in to a single category. Tables were prepared to present the positive responses in numbers and percentages according to the professional year of students. Chi-square test was performed on categorical variables and significance was defined as P < 0.01.

RESULTS

Out of total 265 participants in the survey, 173 (65.3%) were females and 92 (34.7%) were males, which correspond to the gender ratio in our institution. The age of the students ranged from 18 to 23 years. Among the students enrolled for the study, 98 (37%) were studying in second professional, 63 (24%) in third professional and 59 (22.3%) in final professional respectively. The number of interns participating in the survey was 45, which formed 17% of total respondents.

Anatomy was considered the vastest subject of first professional as indicated by 200 (75.4%) students, while only 102 (38.5%) respondents considered biochemistry curriculum as extensive. The number of students who could recall anatomy and physiology during relevant clinical discussions was 174 (65.7%) and 173 (65.3%) respectively. This percentage was relatively low for biochemistry (40%). Approximately, 50% of students considered anatomy as the most important basic science subject. Majority of the respondents (90.6%) felt that problem based learning (PBL) would have helped in better understanding of the subject [Table 1].

Table 1

Attitudes and perceptions of medical students toward basic science subjects

Year wise analysis of responses showed mostly consistent findings with the majority of students satisfied with the practical skills imparted and understood the importance of these subjects for clinical knowledge [Table 1].

DISCUSSION

Traditional basic science teaching has been as individual disciplines unrelated to other basic science disciplines and the future practice. Subjects are taught to prepare students for assessments and unfortunately the process of integrating with other basic science and clinical subjects is not always emphasized.[6] As observed by Vowel, “each discipline is convinced that it represents the most important part of medicine and turns on the spigot of information forcing students to question the relevance or irrelevance of the information.”[7]

Studies have showed that the basic science knowledge learned in a clinical context is better comprehended and more easily applied by students.[8910] Students also understand the importance of PBL as 80-90% of students in our survey felt that this approach would have helped in better understanding of respective subjects [Table 1]. A number of studies reported from India have emphasized the benefit of case study or PBL for better learning outcomes.[1112131415] Though whole of the syllabus cannot be covered by this approach and a hybrid approach has to be adopted in which few topics are covered by traditional didactic lectures and the rest as clinical cases.[14] Moreover, it requires greater coordination among different basic and clinical departments and a motivated faculty committed to improvement in standard of medical education.[12]

Curriculum overload especially in anatomy is an important problem faced by students. The students feel overburdened with study of different aspects of the subject and are able to devote very little time to other subjects. One solution to content overload may be establishing a core curriculum with additional options or special study modules. This method would ensure that students acquire the knowledge, skills and attitudes required for maintaining educational standards, while also allowing them to take more responsibility for their own learning.[16]

The basic subjects are probably being taught in too much detail in 1st year. This view was echoed by the opinion of 37% and 43.8% of participants respectively who felt that instead of teaching anatomy and biochemistry in detail, only a working knowledge of these subjects should be given. The study done by Shankar et al. had also presented similar views of the students regarding 1st year curriculum.[6] However, the students do agree that good knowledge of these subjects is important to be a good clinician. Anatomy, physiology and biochemistry were considered important for understanding of clinical cases by 89.4%, 85.7% and 71.6% of students respectively. A different view though, was presented by El-Bab et al. who opined that clinical knowledge can be acquired without complete understanding of its basic science background.[1] In their study they asked basic science and clinical questions to 2nd to final year students and found that more clinical questions were answered correctly compared with the basic questions. These results implied that the knowledge acquired about medical topics, clinical facts are not always recalled together with the correlating basic knowledge background, but rather that the two types of knowledge are independently acquired and recalled. According to them, “the reason for lower basic knowledge in clinical years’ students may be because clinical textbooks do not provide detailed coverage of basic science background and primary concepts are generally not required in the exams, so they are gradually forgotten.”[1]

The longevity of basic science knowledge learned in medical school has always been a cause of concern. There is a widespread belief among physicians and medical educators that a substantial portion of the basic science information learned in the traditional preclinical years in medical school is lost during the clinical years.[17] This has been supported by many studies.[181920] Miller in 1961 quoted that “it is not uncommon for students to retain a mere 10% of the anatomy or biochemistry offered in the traditional 1st year course.”[21] Things have not changed since then. A recent study has reported significant knowledge loss among students when the questions asked to them in 1st year were asked again during 2nd year.[4] Another cross-sectional study in Saudi Arabia reported that 21%, 19% and 50% of their students were able to recall anatomy, biochemistry and physiology respectively in their clinical years.[5] Our study shows better results with biochemistry being the least remembered subject with 40% students able to recall it. Approximately 65% of students felt that they were able to recollect the facts related to anatomy and physiology during relevant clinical discussion. “Differences in retention between basic sciences can probably be accounted for by differences in rehearsal or reinforcement.[17] The general picture is that gross anatomy shows a modest loss[192223] while reports for physiology range from no decrement[22] to moderate decrements whereas, biochemistry appears to be a more vulnerable subject.”[17]

CONCLUSION

The study presents a positive attitude of students for basic sciences. They understand the significance of these subjects for inclusive medical aptitude and knowledge. The learning experience for them can be improved significantly by better clinical integration of subjects.