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\begin{document}
\title{Investigation of the importance and achievability of early clinical
exposure goals (ECE) from the viewpoints of basic sciences medical
students of Mashhad Islamic Azad University and its comparison with
their academic performance}
\author[1]{Samaneh Sarvghad Moghadam}%
\author[2]{Leila Bazrafkan}%
\author[3]{arezou farajpour}%
\affil[1]{Education Development Center, Mashhad Branch, Islamic Azad University, Mashhad, Iran.}%
\affil[2]{Shiraz University of Medical Sciences}%
\affil[3]{Affiliation not available}%
\vspace{-1em}
\date{\today}
\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup
\selectlanguage{english}
\begin{abstract}
background: Early clinical exposure could enhance students' learning in
the emotional and cognitive domains, socialization with the profession,
and the development of professional personality and professionalism. It
can also provide a suitable opportunity for future career recognition by
creating a more appropriate image of the medical profession. Therefore,
the present paper aims at investigating the importance and achievability
of early clinical exposure goals from the viewpoints of basic sciences
medical students and its comparison with their academic performance.
Methods: In this descriptive cross-sectional study, 100 medical students
were admitted to the hospital after 34 hours of workshop training on
professional principles during the first two semesters. They experienced
and practiced their lessons learned in the clinical context. The data
collection instrument of the study was the ECE Questionnaire. Its face
and content validity were confirmed and reliability was calculated to be
0.926 through Cronbach's alpha. Results: In 93 studied students with the
mean age of 21.34\selectlanguage{ngerman}±1.363, the mean score of the importance scale of
objectives was 99.31±8.59, and the achievability scale was 81.62±13.75,
which indicates that despite the high importance of the objectives of
the program for students, achieving those objectives is not easy. Also,
the educational importance of the objectives of the course and the
achievability of the objectives had a significant statistical
relationship with the academic performance of students and had no
significant statistical relationship with gender and age. Conclusions:
The students held the importance and achievability of the objectives of
the ECE program in high regard. More successful students take the
importance and achievability of the objectives of the ECE as
significantly more important. Despite the high importance of the
objectives set out, achieving these objectives is not easy, and this
part of the program requires more educational planning and design.%
\end{abstract}\selectlanguage{ngerman}%
\sloppy
\textbf{Backgrounds}
Organization of the content of medical education and implementation of
vertical integration and spiral curriculum strategies in undergraduate
medical education is an important topic in formulating the related
curriculum around the world\textsuperscript{1}. The goal of the medical
profession is to relieve pain - not only physical, but also afflictions.
Communication with the patient and the community is one of the most
basic medical practices. Communication comes from getting to know each
other and facilitates recovery for the patient. If we do not just
analyze the patient through the biomedical view, and acknowledge that we
have a fellow for whom the human, psychological, social, economic and
occupational aspects contributed to the disease, and we take into
account all of his human, personal, and behavioral aspects of the
treatment, the treatments will become more effective and
useful\textsuperscript{2}.
The extended changes that have occurred in recent years in terms of
disease patterns, demographics, mortality patterns, risk factors
affecting society, the individual and his health status have led to
changes in physician responsibilities, his relationship with the
patient, and thus the type of education. Medical education courses
incorporate various stresses, including dealing with unfamiliar
educational contexts such as clinical education environments. Early
clinical exposure (ECE) has been suggested as one of the strategies to
reduce professional stress, orientate students' professional attitudes,
and create motivation \textsuperscript{3}. It is considered an important
part of educational courses in the developed
countries\textsuperscript{4}. Familiarity of the medical students with
the early clinical exposure in the very early years, i.e. before the
clinical course formally begins, was practiced about a century ago in
the medical schools around the world \textsuperscript{5}. The common
approach to the medical education over the last century has been
theoretical education in medical schools for 2 to 3 years before the
start of the clinical course. This medical education approach has been
about to change over the last century. So, many medical schools around
the world are implementing vertical integration programs, and nowadays,
early clinical exposure with the patient \textsuperscript{6-8}. In a
study by the European Academy of Teachers in General Practice (EURACT)
in 2006, from among 32 member states, 40 medical schools from 16
countries were studied. Thirty two (80\%) medical schools implemented
the ECE program during the first year, with the duration of the course
varying between two weeks to two years and the duration of each session
between 2 hours to the whole day \textsuperscript{9}. It is generally
believed that this method could enhance students' learning in the
emotional and cognitive domains, socialization with the profession, and
the development of professional personality and professionalism
\textsuperscript{7, 10}. Early clinical exposure also enhances
understanding of health and primary care, self-directed learning,
empathy with patients, motivation for better learning of the basic
science, increases satisfaction, provides a correct attitude towards
future profession, provides the possibility of observing
physician-patient relationship, familiarity with hospital environment
and learning some simple clinical skills\textsuperscript{11-13}. In
other words, early clinical exposure approach is one of the suggested
strategies for solving the challenge of learning and teaching basic
medical sciences students and intangibility of the general intangibility
of the relationship between basic sciences and clinic contexts, and also
the distance of basic sciences students from the moving on the path of
making a physician. Lack of proper communication and experience in
transitioning to the clinical environment could lead to a wide range of
positive and negative emotions. Not only may it disrupt the formation of
the fundamental concepts in basic sciences and also the practical
understanding of courses, but also, it may affect motivations and
abilities of the student negatively \textsuperscript{14}. Given the
negative attitudes toward medicine that is formed in the very first
years, and the numerous reports that mentioned the positive effects of a
familiarity with, and early exposure to the clinical environment, one
can conclude that these courses can positively influence the students'
needs, motivations and attitudes, and consequently their academic
performance in the future. This could even provide students with a
better image of the medical profession as a good opportunity to know
about their future occupation, something that is not possible in many
other disciplines. While in our country, students are away from the real
medical and clinical environment up until the fourth year of medical
education\textsuperscript{15, 16}, this program can facilitate the
learning of basic sciences curriculum. Vertical integration in medical
education is not a new experience; however, there are not many
systematic reviews on this program and its benefits. In the current
environment, there is a need for credible evidence on the program, based
on which, to draw on the goals and outputs expected of the program and
consequently the educational practices used in its implementation
\textsuperscript{17}. Although there are already good theoretical
foundations for establishing early clinical exposure for students, the
concrete implications of such programs have not yet been clearly defined
\textsuperscript{18}. Early Clinical Exposure Program started in 2017 at
Islamic Azad University of Mashhad, and is implemented every semester.
Therefore, the present paper aims at investigating the importance and
achievability of early clinical exposure (ECE) from the viewpoints of
basic medical sciences students and its comparison with their academic
performance. Given the above, it seems useful to consider such an
intervention in the early years of academic education.
\textbf{Methods}
This is a descriptive cross-sectional study, for investigating the
importance and achievability of early clinical exposure (ECE) from the
viewpoints of basic medical sciences students at Islamic Azad University
of Mashhad and its comparison with their academic performance. The
proposal was approved by ethical committee in Shiraz University of
medical science. The statistical population of this study consisted of
medical sciences students, with a number of 100 according to the Census
Bureau. Due to the limited statistical population, a census sampling
method was used. After about 34 hours of workshop training in the first
two semesters on the nature of medical field, principles of professional
ethics and behavior, communication with patients, hierarchies and
descriptions of various disciplines, quality improvement mechanisms and
dealing with medical errors and patient safety, the students attended
the hospital and practiced what they learned in the clinical
environment. Some of the issues highlighted included: implementation of
the principles of medical professional dress codes, familiarity with the
physical structure and hospital departments, familiarity with hospital
hierarchies and interactions of different groups, initial communication
and empathy with patients, observing professional interactions in the
environment, and acquaintance with professional realities in areas such
as emergency, ICU, and hemodialysis, hand washing, application of basic
sciences for the patients and paraclinic and so on.
In order to study the achievement of the goals and importance of the
program from the students' viewpoints, the ECE Questionnaire was used in
8 main areas (medical ethics, scientific skills, primary care,
communication skills, patient-centered care, familiarity with clinical
education, integration of basic and clinical science and motivation for
learning basic sciences). The minimum score of the questionnaire is 22
and the maximum is 110 \textsuperscript{19}. This questionnaire was
developed in Adibi et al. to assess the ECE courses, so it investigates
the students' attitudes toward the importance and achievability of its
goals separately in two five-point Likert scales (1= insignificant to 5=
very significant; and 1= not achievable at all to 5= easily achievable).
The face validity of the questionnaire was confirmed by three experts
and its reliability was calculated by Cronbach's alpha. This
questionnaire was used in 2005 by Adibi and Kiani Nia its face and
content validity was confirmed by the experts \textsuperscript{19}. The
reliability of the questionnaire was calculated by Cronbach's alpha to
be 0.926. Students were reminded that the results of this study were
solely to be used for the project goals and would not affect their
educational and evaluation process. Questionnaires were collected
anonymously after obtaining informed consent from students. The academic
performance variable (the grade point average of the previous semester)
was investigated for both the importance and the achievability of the
goals of the program. Data analysis was performed by SPSS 21 software
using Pearson correlation coefficient and Mann-Whitney test.
\textbf{Results}
93 among the 100 students studied completed and submitted their
questionnaire and the response rate was 93\%. Of these, 27 (29\%) were
males, 66 (71\%) were females. 8 (8.6\%) were married and the rest were
single. The age range of participants was 20-26 and the mean age was
21.34\selectlanguage{ngerman}±1.363. The grade point average of the students ranged from 13 to
19.54 with a mean of 16.43±1.43.
The score range of the students in the importance of the ECE program
goals was 73-110 with a mean of 99.31±8.59. Also, the score range of the
students in the achievability of the ECE program goals was 44-105 with a
mean of 81.62±13.75. Table 1 shows the mean and standard deviation of
scores of each questionnaire item in terms of both the importance and
the achievability of the ECE program goals.
Table 1. Mean of the scores of students in terms of the importance and
the achievability of the ECE program goals
The results show that the mean score of all items of the importance of
the ECE program goals is over 4 on the five-point Likert scale
(1=insignificant to 5=very significant). However, the mean score of
student on the achievability of ECE program goals is below 4 on the
five-point Likert scale (1= not achievable at all to 5= easily
achievable), except in the items 1, 3, 17 and 18. In other words,
despite the fact that students placed a high importance on the goals of
the ECE program, they believed that achieving these goals was not easy.
The normal distribution of the data was analyzed using
Kolmogorov-Smirnov test (P \textless{}0.05) and so the data are not
normal. Mann-Whitney test was used to analyze the data.
Statistical analysis revealed that there was a significant relationship
between the importance of the goals of course and the academic
performance of the students (P=0.371, r=0.0001). It is indicated in
Diagram 1. However, it does not have a significant relationship with the
gender (Mann-Whitney =-0.477, P=0.633) and age (r=0.095 and P=0.376) and
marriage status (Mann-Whitney=-1.923 and P=0.054) of the students.
Picture-1
Statistical data also show that there was a significant relationship
between the achievability of the goals with the academic performance
(P=0.004, r=0.293) and marriage status (Mann-Whitney=-2.119, P=0.034).
It is shown in Diagram 2. However, it does not have a significant
relationship with gender (Mann-Whitney=-0.790 and P=0.429) and age
(r=-0.003, and P=0.974) of the students.
Picture-2
\textbf{Discussion}
93 medical students of Islamic Azad University of Mashhad participated
in this study. Of the 93 students studied, 85 (91.4\%) were single and 8
(8.6\%) were married and the mean age was 21.34±1.363. this study tried
to investigate the importance and achievability of the goals of the ECE
program from the viewpoints of basic medical sciences students.
Comparison of the mean scores at the two scales showed that students
underestimated the achievability of program goals than their importance.
But despite the high scores on both scales, this result clearly
demonstrates that students are aware of the importance of this training
program and its goals and are aware of the achievability of the goals.
They know that these goals cannot be easily achieved. In line with the
present study, in another study entitled ``What goals should be sought
in ECE courses?'', Adibi et al. concluded that the median score of the
importance of all items of the importance of the ECE program was equal
or greater than 4. The mean score of the achievability of the goals of
this program was 3 in 8 items, and it was 4 in other goals. Overall, the
students agreed with the importance and achievability of the selected
goals \textsuperscript{19}. In a 2017 study by Guvindaraja et al. in
India on the impact of the ECE program on basic medical sciences
students, it was found that the program had a significant impact on
cognitive, mental and motor domains. The qualitative analysis of
students' views provided the themes of ``applications of the basic
sciences in clinical practice'', ``learning motivation'', ``acquaintance
with different specialties'', and ``insight on what is happening to
patients'' \textsuperscript{20}. On the implementation of ECE in
Thailand, the students took this course as a presentation of the value
of professional and clinical medical roles and reported this experience
as encouraging and motivational \textsuperscript{21}. Achieving the goal
of integrating the basic sciences and clinical sciences in the ECE
program was successful in most studies \textsuperscript{22, 9}. Numerous
other studies, conducted at Shiraz University of Medical Sciences and
Sabzevar University of Medical Sciences, also suggested that ECE is good
or excellent in increasing motivation, increasing interest in learning
basic sciences, and increasing sensitivity to patients' problems and
needs \textsuperscript{23}. The results of Kojuri et al., who aimed to
evaluate the success rate of the ECE program for first year medical
students in Shiraz, showed that this program was effective in creating a
new attitude in 80\% of learners \textsuperscript{3.} Karimi et al. also
showed that 95.5\% of students rated the ECE course as useful. 83.3\%
also believed that early clinical exposure led them to enjoy studying
medicine in the future \textsuperscript{24}. In line with this study,
another study found that the students' satisfaction with the ECE program
was 82\%, time of program implementation 66\%, necessity of continuation
of program 54\% and impact of program on their cognition and attitude
77\%. In most studies on ECE, satisfaction with courses and enhancement
of students' positive attitudes were reported \textsuperscript{19, 23,
25}. Other important results of this study were to investigate the
relationship between importance and achievability of the goals of the
ECE program and their academic performance. The results showed that
there is a significant correlation between the achievability and
importance of the goals of the ECE program and their academic
performance. In their study entitled ``Investigation of the effects of
ECE program on changes in attitudes of basic medical sciences students
considering the methods of preparation for entering clinical course in
Internal Medicine, Surgery and Pediatrics'' during 2013-2014'', Seif
Rabi'ie et al. examined the effect of ECE program on students'
end-of-semester grades. At the beginning of this study, the frequency of
those agreed with the effects of ECE before the start of the program was
5 students, and after the program it was 13 students. Subsequently,
comparing the academic scores of the students, it was concluded that
although the students' scores were higher after the program, there was
no significant difference between the mean scores of the students before
(1.92) and after the (2.07) the ECE program (p =
0.74)\textsuperscript{26}. Investigating the relationship between
demographic variables and the importance and achievability of the goals
of the ECE program showed that gender and age are not important factors
in students' view of importance and achievability of the goals of the
ECE program, however, the marital status is related to their views of
the achievability of the goals. In terms of gender difference, however,
in the study of Adibi et al., there was a more positive attitude toward
the ECE program in women than men, which is inconsistent with the
present study \textsuperscript{19}. In the present study, there was no
significant difference between men and women in terms of the attitude
toward the ECE program. Considering that this study was performed in a
small-scale, it is recommended to conduct more extensive qualitative
studies in order to investigate the factors affecting students'
attitudes toward the importance and achievability of the ECE course.
\textbf{Conclusions}
Students reported high importance and achievability of the goals of the
ECE program. The results show that more successful students consider the
importance and achievability of these goals significantly higher than
other students. However, the high importance of these goals does not
generally make their achievement easier. So, this aspect of the program
requires more educational planning and design.
\textbf{Abbreviation}
\textbf{ECE} : early clinical exposure
\textbf{EURACT:} European Academy of Teachers in General Practice
\textbf{Declarations}
\textbf{Competing interests:} there is no competing interest. -
\textbf{Funding:} This article is the result of a master thesis in
medical education at Shiraz University of Medical Sciences.
- \textbf{Authors' Contributions:} Each author is made substantial
contributions to the conception and design of the work; and the
acquisition, analysis, and interpretation of data; and have drafted the
work or substantively revised it and to have approved the submitted
version (and any substantially modified version that involves the
author's contribution to the study); and to have agreed both to be
personally accountable for the author's own contributions and to ensure
that questions related to the accuracy or integrity of any part of the
work.
\textbf{- Acknowledgements:} the authors would like to acknowledge all
of medical students that participated in this study.
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\end{enumerate}\selectlanguage{english}
\begin{longtable}[]{@{}llllll@{}}
\toprule
\begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Importance of goals}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Importance of goals}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
Row\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{ECE program goals}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Achievability of goals}\strut
\end{minipage} & \begin{minipage}[b]{0.14\columnwidth}\raggedright\strut
\textbf{Achievability of goals}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SD.\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mean\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
Mean\strut
\end{minipage} & \begin{minipage}[t]{0.14\columnwidth}\raggedright\strut
SD.\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.00\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.41\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Learning simple clinical preparations such as dress code of medicine and
hand washing\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.44\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.73\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.06\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
2\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Communication with the patient and assessment of the impact of the
disease on his individual and social lives\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.63\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.51\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.13\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.15\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Getting acquainted with the hospital environment and its different
departments\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.37\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.95\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.20\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Increasing students' motivation to study medicine\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.67\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.52\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.08\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.72\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
5\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Creating the right attitude towards the medical profession\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.71\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.48\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.01\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.80\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
6\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Taking responsibility for the patient's life and personality\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.86\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.35\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.00\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.72\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
7\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Learning to take the patient as a human, not a case or a disease\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.75\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.46\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.86\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.69\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
8\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding the importance of the right physician-patient
relationship\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.54\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.62\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.19\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.71\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
9\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding that medicine, while a science, is an art and a
profession\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.52\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.73\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.30\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.46\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
10\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Observing the realities of the medical profession tangibly\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.55\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.68\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.22\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.30\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
11\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Becoming familiar with the concept of self-centered learning and problem
solving in medicine\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.53\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.03\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.28\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
12\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Having the ability to communicate effectively with the patient\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.55\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.56\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.13\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.67\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
13\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding the importance of the role of other health care
professionals\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.30\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.97\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.71\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
14\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding the physician's responsibility toward community
health\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.48\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.60\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.14\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.60\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
15\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding the importance of teamwork in the medical profession\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.61\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.63\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.30\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.28\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
16\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Getting the ability to communicate between what they learned in basic
sciences and clinical practice\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.32\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.93\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.25\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.01\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
17\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Understanding the different stages of clinical education\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.43\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.94\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.88\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.13\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
18\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Learning about the different rankings of medical education staff\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.40\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.78\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.27\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.51\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
19\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Becoming familiar with the applications of common paraclinics\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.38\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.78\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.99\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.44\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
20\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Communicating with senior students and physicians\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.04\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.00\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
1.12\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.97\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
21\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Learning about the mechanisms for quality improvement and dealing with
medical errors in the hospital\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.78\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.46\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.96\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
3.87\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
22\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
Observing the path a patient takes in an educational hospital\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
4.38\strut
\end{minipage} & \begin{minipage}[t]{0.16\columnwidth}\raggedright\strut
.69\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}
\end{center}
\end{figure}
\textbf{Picture-1}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}
\end{center}
\end{figure}
\textbf{Picture-2}
\textbf{Hosted file}
\verb`Pictures.docx` available at \url{https://authorea.com/users/288203/articles/413317-investigation-of-the-importance-and-achievability-of-early-clinical-exposure-goals-ece-from-the-viewpoints-of-basic-sciences-medical-students-of-mashhad-islamic-azad-university-and-its-comparison-with-their-academic-performance}
\textbf{Hosted file}
\verb`tables.docx` available at \url{https://authorea.com/users/288203/articles/413317-investigation-of-the-importance-and-achievability-of-early-clinical-exposure-goals-ece-from-the-viewpoints-of-basic-sciences-medical-students-of-mashhad-islamic-azad-university-and-its-comparison-with-their-academic-performance}
\selectlanguage{english}
\FloatBarrier
\end{document}