The current study investigated the design, implementation, and evaluation of clinical presentation activities combined with patient encounter experience and community-based stroke education program in the first year of medical school. Students’ performances were higher in the summative when compared with the formative assessments. This is because the questions used in the formative assessments were more challenging and the goal was to encourage deeper levels of learning to reflect the format and difficulty anticipated for the final summative assessment. Therefore, medical students developed their critical thinking skills in clinical issues through clinical presentation and in the formative assessments, which were more challenging written clinical vignette questions than the summative examination. They were able to construct clinical outcomes in a logical and systematic sequence that may be applicable in real-life clinical practice settings. Following repeated practice in the solving of clinical problems through analysis of clinical cases in the clinical presentations, they developed a pattern recognition skill in patient problems. Therefore, the schematic structural framework provided in our clinical presentation and formative questions provided the background and direction that helped medical students, especially in the pre-clerkship phase to shape their clinical reasoning by organizing their knowledge in ways that can help solve specific clinical problems [18]. The strong performance in the summative assessment indicated that they were able to retain and use basic science concepts to provide a contextual analysis of specific clinical problems [19], allowing effectiveness in chronological and logical thinking resulting in a strong performance in summative assessment.

Following the implementation of clinical presentations, we then exposed medical students to directly interact with patients with neurological disorders and most of them were actual cases on whom clinical presentation learning activities occurred earlier. Medical students interacted with stroke, Alzheimer’s dementia, Parkinson’s disease, traumatic brain injury, cerebral palsy, epilepsy, primary lateral sclerosis, Charcot-Marie-tooth disorder, inclusion body myositis, multiple sclerosis, myasthenia gravis, and spina bifida patients in the patients encounter session. In addition, the patient’s encounter experience was based on neurological presentations in the healthcare system as identified in the need assessment outcome. We provided the opportunity for medical students to directly connect with the patients in real-world experience in a nonclinical setting.

In the post-test evaluation of the patient encounter with medical students, we observed that medical students demonstrated a higher perception of their experience in all assessment categories. Patients and family members shared their personal experiences as well as the treatment outcomes, family challenges, and the importance of a physician who is honest, empathetic, and open with his or her patients. Medical students learned from patients about the humility, listening, and communication skills that make a clinician a good doctor. This is important as effective provider communication skills have been reported to be a key factor in ensuring better patient outcomes, reduced medical errors, and greater compliance with treatment plans [20, 21]. The patient encounter experience provided an opportunity for students to hear directly from patients about their experiences and standpoints on their health conditions [22]. Communication has also been reported to help in strengthening the conceptualization of the patient perspective by identifying aspects that, from doctors’ point of view, are important to address during a consultation to build a partnership with patients in receiving better healthcare [23, 24]. In general, our finding also reveals that patient interactions in an integrated medical curriculum during the first year has a significant impact on laying the foundation for their future clinical practice by fostering essential communication skills, building empathy, and providing real-world context to theoretical knowledge, while later interactions continue to improve these abilities and allow for more complex patient care management. Therefore, early exposure to patients is critical for building confidence and shaping a patient-centered strategy to medicine, allowing medical students to better understand the social and psychological context associated with a patient’s health condition, and this can inform future treatment decisions.

While clinical presentation activities may enhance medical students theoretical and pragmatic knowledge of disease processes with emphasis on diagnostic and treatment modalities [25, 26], they may not address the engagement skills that are very important in interacting with patients. We address this issue by providing the opportunity for medical students to interact with patients and their families in the patient encounter experience. A major rationale for patient encounters is that the trust and lessons that emerge between both parties when patients tell their stories cannot be entirely communicated through lessons in the clinical presentations. Our findings indicate that medical students perceived the encounter with patients to have provided them with meaningful experience, they learned lessons about empathy, and the diversity of patients’ experiences, clinical reasoning skills, future trust in the doctor-patient relationship, and skills needed for effective engagement with patients and families in their future practice. This is because patients shared with medical students about how much the quality of their care is connected to the physician’s empathy, which improves patient satisfaction [22], treatment compliance [27, 28], and clinical outcomes [28], as most patients indicate that they were more likely to follow their treatment plan and practice self-care when they feel heard and understood by their physicians. Therefore, our approach provided multiple benefits including changes in students’ attitudes toward patients, knowledge, and understanding related to patient-doctor communication, as well as new insights into psychosocial aspects of patients’ everyday life with the disease. Finally, by including patients and families in the curriculum, we created strong partnerships in the development of medical education programs and culture where partnerships with patients, families, and communities added a positive context to make a difference in the education of future doctors.

Our need assessment identified specific healthcare issues including that the region is within the stroke belt area, and obesity and cardiovascular diseases, including diabetes, are prominent healthcare issues in the community. This informed our decision to develop community-based stroke education that allowed the curriculum to directly contribute to addressing healthcare issues in the community including stroke and related risk factors. We observed that medical students demonstrated a higher perception of the program for their improved interprofessional community-based learning, adequate education measures in the program for prevention actions and behavioral and health change, and a better understanding of socio-economic factors in the underserved community, social inequalities, and determinants of health. Therefore, the community-based stroke education program directly targeted healthcare issues implemented by medical students who are committed to serving rural communities. It provided the opportunity for the curriculum to contribute to providing a practical solution to community needs.

Medical students worked in groups that comprised nurses, clinicians, and biomedical faculty members to implement the community-based stroke education program. Therefore, our program provided contextual learning with other health professions that introduced the concept of interprofessional collaborative practice [29,30,31] with a model of underserved community-based care. Medical students agreed or strongly agreed that the community-based stroke education program adopted adequate education measures for prevention actions that targeted underserved populations to achieve behavioral and health change. They strongly agreed that the program contributed to a better understanding of social inequality in healthcare issues, and social determinants of health. Our finding is supported by other studies [32,33,34] that community-based education may promote socio-behavioral aspects of medical students in understanding other factors than diseases that influence clinical conditions. Such factors include the social determinants of health, the conditions in which people are born, grow, live, work, and age affected by health issues [35, 36]. Therefore, our community-based education program allowed medical students to fully understand the influence of social determinants on individual patients, their families, and the community, and they reflected on learning during intensive exposure to community health problems [37].

Community-based educational activities are reported to provide a conducive environment to educate medical students more about health problems when compared to hospital-based settings [11]. In our community-based stroke education program, medical students learned the context of the epidemiological change, where a paradigm shift from disease-oriented care toward disease prevention was a major focus [38]. Therefore, we integrated community-based medical education in the delivery of integrated medical education in a specific social context, where medical students were part of the communities and actively participated in the implementation of the program to reduce the impact of stroke and related risk factors in the underserved community.

This study has some limitations. This was a pilot study at a single institution for a single course, and the results may not be generalizable to other institutions. However, integrating patient interactions in a clinical presentation curriculum of an integrated curriculum and allowing medical students to participate in community-based activities can be adapted for use in other institutions. While we collected data on students’ perceptions, we should have collected data on teachers as well as community members. Teaching foundational science in the clinical environment is challenging, requiring supervising clinicians to have the time and the knowledge to participate during patient encounter sessions. The long-term outcomes of this curriculum innovation are unknown/remain to be seen. Furthermore, there are opportunities for us to provide physician faculty development to help them teach foundational science at the depth that is expected in the clinical presentation sessions. Such a faculty development program should entail implementing activities to improve skills in designing, developing the objectives that integrates basic, clinical, and health system science and the implementation of a clinical presentation session. It should also include building active learning strategies to help students in solving the clinical problems. Such activities can enhance support curriculum innovation by helping faculty members develop the skills and knowledge they need to teach and facilitate student learning.