Medical Council of India (MCI) envisages an Indian medical graduate (IMG) to have both clinical skills and also right attitudes, professionalism, and ethics [1], which were included as an Attitude, ethics and communication (AETCOM) module [2]. Competency-based medical education (CBME) was proposed to revamp the existing medical teaching to replace it with a more uniform and objective prototype [3].

A foundation course of one-month duration has been introduced throughout India from August, 2019 as a compulsory module at the beginning of the MBBS course to sensitize students to information, lifestyle and practical skills required to sail through the training [4]. This study aimed to record the reactions and learning of students who undertook the foundation course.

Data were collected as an online Google form administered in the English language and disseminated via an online link in an email to the students. All undergraduate students who joined our institution, a public medical college in Northern India, were administered the survey before completion of the foundation course in the fourth week of August, 2019.

Permission for the study was obtained from the institutional ethics committee. Consent was obtained before sending the link for the online form. The information was collected in an anonymized form. A provision for the hard copy of the form was available for students who were not well-conversant with the online usage. Faculty-volunteers assisted students who needed language-support for filling the form.

The semi-qualitative questionnaire used consisted of four sections viz., Demographic information; Clinical medicine knowledge and skills; Medical ethics including professionalism (student’s experience and understanding of foundation course, its relevance, competency in medicine, role of a doctor in the community and perception about attitude, ethics, and communication in medical curriculum); and Beyond curriculum (extracurricular activities and interests of students with their perceptions about the need for sports, technology and recreation, and their experiences with peers, seniors and faculty). Clinical medicine section evaluated knowledge-based responses pertaining to skills module and orientation to clinical medicine, which was discussed during the foundation course (post-test). Pretest for this content was not taken separately, as it was considered that factual knowledge on these concepts would not be available to the students. The questions in this section were related to the immunization schedule, first-aid, waste management, universal precautions and basic life support. The responses were converted to a score and scored from 0 to 1. Participants with a correct response to questions were given a score of 1, a partially correct response received 0.5, and an incorrect response received zero.

Data were recorded on a Google excel sheet and analyzed using SPSS version 23. A five-point Likert scale was used to report the overall experience of the foundation course.

Out of a total of 250 students enrolled, only 129 (51.6%) participated, with mean (SD) age 18.2 (1.1) year (range 17-23). Reasons for non-participation among the rest were not available. The majority of respondents (56%) were residents of Delhi, and most were conversant both in English (97.7%) and Hindi (93.8%).

The overall feedback on the foundation course was positive (average score of 3.9 out of 5) on the Likert scale. Table I details the students’ perceptions of the foundation course. The positive experiences with foundation course included interactive sessions and simulation-based learning, team-building activities with peers, seniors and teachers, college campus tours, the inclusion of cultural activities and yoga, and visits to hospital and community outreach center. Three students did not feel the need for a foundation course, and one regretted joining MBBS. The unpleasant experiences highlighted by few included long college hours, long duration of the foundation course, parental separation anxiety, lesser exposure to the clinical side, poorer ice-breaking activities, lack of cleanliness in college campus and hostel, and the requirement for better physical activities and sports. The majority (94%) identified lack of time as a major constraint to pursue hobbies.

Table I Perceptions of Undergraduate Medical Students After Completing a One-month Foundation Course (N=129)    

		Component of training

		*No. (%)

		Overall course 

		Necessary for the right attitude

		119 (92)

		Provided orientation of knowledge and skills 

		115 (89)

		  required in MBBS

		Helped to identify roles of IMG

		95 (73.6)

		Identified research as important for IMG

		119 (92)

		Understood need and role of CBME

		81 (63)

		Found course boring and lengthy 

		20 (25.8)

		AETCOM 

		Empathy, attitude, and communication important 

		105 (81.4)

		  for IMG

		Role of non-verbal communication in medicine

		52 (40.3)

		*Positive response; CBME: competency-based medical education; IMG: Indian medical graduate; AETCOM: Attitudes, ethics and communication module.

The mean knowledge scores under the skill module are shown in Table II. The highest scores were seen in the clinical skill areas (first-aid and safe injection practices, >85%).

Table II Clinical Medical Knowledge and Skills of Undergraduate Medical Students After a 
One-month Founduction Course (N=129) 

		Question

		Score (%)

		AYUSH components

		116 (89.9)

		Safe injection practices 

		110 (85.3)

		First aid 

		110 (85.2)

		National immunization program

		108 (83.7)

		E-learning platforms

		103 (79.8)

		Hand washing 

		102 (79.1)

		Biomedical waste management 

		102 (79.1)

		Universal precautions 

		89 (68.9)

		International classification of diseases 

		87 (67.4)

		Healthy lifestyle 

		73 (56.6)

		Basic life support  

		72 (55.8)

		AYUSH: Ayurved, Unani, Siddha and Homeopathy.

A foundation program was initiated in 2004-05 in United Kingdom for newly joined postgraduate students [5], and evaluation of the impact on doctors in training found that foundation course improved the perceived confidence and competence; though, the survey could not reliably assess the quality of care that was provided to patients [5]. Such information for foundation course during undergraduate medical courses are lacking in the published literature.

Studies have shown that learning during the medical curriculum depends upon students’ gender, race and ethnicity [5-7]. The perceptions about the medical school environment also change with the progress of the curriculum [6]. A survey on about 4000 medical students from United States and Canada revealed that perception scores for learning environments had declined during clinical exposures. A systematic review analyzed 28 medical schools with 4664 students for the medical school learning environment survey (MSLES) scores and student characteristics [7]. They found that demo-graphic characteristics across different schools and medical school environment accounted for 2.2% and 15.6% variation in MSLES scores, respectively [7]. Therefore, understanding of students’ perceptions about learning and the environment could facilitate overall course delivery and learning.

Medical informatics is the science and art of processing medical information [8]. Computer-assisted learning and problem-solving learning are powerful tools that can improve lifelong learning of medical students [9]. A fair number of students in the present study were aware of e-learning and its use in the medical field, suggesting that this technology can be used during the curriculum for an improved learning experience, and address the issues of the time- and faculty-shortages.

The present study could not quantify the impact of the foundation course for improvement in knowledge as a pre-test questionnaire was not administered. The change in behavior and improvement in patient-care resulting from the course would need to be studied over the long-term by other researchers. Despite a large sample, this was a single-center study, and the results may not be generalizable to other settings, as the course-content or delivery methods may be different at other centers. However, we have highlighted the key aspects of qualitative experiences related to the foundation course, which may guide curriculum-planners for formulating future programs.

To conclude, the foundation course was reported as a pleasant and beneficial experience by undergraduate students. An improved understanding of their aspirations and concerns will aid in the development of a better curriculum and training module.

Contributors: AD, DV, DK: conceptualized and planned the study; DV: supervised the study conduct and data collection, and would be the guarantor; AD: prepared the initial draft of the manuscript and did the statistical analysis; DK: assisted in planning the study, participated in data collection, and statistical analysis; DM: assisted in planning, outcome assessment, manuscript finalization and data analysis. All authors approved the final manuscript.
Funding: None; Competing interest: None stated.

References

1. MCI Booklet. Vision 2015. Available from: https://old.mciindia.org/tools/ announcement/MCI_booklet.pdf. Accessed June 12, 2019.

2. Medical Council of India. Undergraduate curriculum. Available from: www.mciindia .org/CMS/wp-content/uploads/2019/01/UG-Curriculum-Vol-I.pdf. Accessed June 12, 2019.

3. Modi JN, Gupta P, Singh T. Competency-based medical education, entrustment and assessment. Indian Pediatr. 2015;52:413–20.

4. Medical Council of India. Foundation course for undergraduate medical curriculum, 2019. Available from: https://old.mciindia.org/UG-Curriculum/FOUNDATION-COURSE-MBBS -17.07.2019.pdf. Accessed June 12, 2019.

5. Mason S, O’Keeffe C, Carter A. An evaluation of foundation doctor training: A mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]. Southampton (UK): NIHR Journals Library; 2013 Dec. (Health Services and Delivery Research, No. 1.15.) Available from: www.ncbi.nlm.nih.gov/books/NBK259534/. Accessed 15 October, 2019.

6. Dunham L, Dekhtyar M, Gruener G, CichoskiKelly E, Deitz J, Elliott D, et al. Medical student perceptions of the learning environment in medical school change as students transition to clinical training in undergraduate medical school. Teach Learn Med. 2017;29:383-91.

7. Skochelak SE, Stansfield RB, Dunham L, Dekhtyar M, Gruppen LD, Christianson C, et al. Environment at the end of the first year: A 28-medical school collaborative. Acad Med. 2016;91:1257-62.

8. Sarbadhikari SN. Basic medical science education must include medical informatics. Indian J Physiol Pharmacol. 2004;48:395-408.

9. Dhir SK, Verma D, Batta M, Mishra D. E-Learning in medical education in India. Indian Pediatr. 2017;54:737-42.