Study participants and the study setting
Study participants were 3rd year students (n = 43) at a private mid-sized medical school located in a suburb in South Korea. The school has a four-year basic medical education curriculum, and the 3rd year curriculum ran from January 2019 till February 2020, during which students attended core clerkships. Students underwent OSCEs twice during the Year 3 curriculum, that is, initially in June 2019 and then again in February 2020. The OSCE comprised six stations with 10 minutes allocated for each station at which they interacted with standardized patients. Students were assessed for their clinical competences in history-taking, physical examinations, and patient-doctor relationships (patient-physician interactions).
We designed and implemented an educational intervention implemented for Year 3 students in 2019 to promote the development of students’ clinical competencies and enhance their clinical performances as their performance in the first round of OSCE was short of the national average. This self-directed learning course ran for six months and was awarded one credit-hour. Students engaged in learning activities intended to promote their reflection and self-directed learning on clinical performance using e-learning resources. During the course, students wrote a reflective paper on their OSCE performance. The purpose of this reflective paper was to promote student self-assessment of his/her clinical performance. For this reflection students first reviewed their clinical performances by watching video clips of themselves at OSCE stations and then rated their clinical performances using a 5-point Likert-type scale in 14 areas from history-taking, physical examinations, to patient-doctor relationships, and overall performance. Based on this self-assessment, students wrote a reflective paper on their OSCE performances.
In addition to self-reflection, students engaged in self-directed e-learning of clinical performance. The e-learning resources were provided by the Korean Consortium for e-Learning in Medical Education (www.mededu.or.kr), which were developed and shared by nationwide medical schools. This website offers online clinical videos of duration approximately 10 minutes per station that show patient encounters for over 40 clinical presentation topics and demonstrate the entire process of patient encounters in a clinic setting. Further information on these video resources is provided elsewhere [18]. Students were asked to analyze patient encounters shown in video clips in terms of history-taking and physical examinations and asked about the information obtained and patient problems based upon the schema of clinical presentations. Students wrote a report on their analysis of patient encounters after watching at least six video clips, and were free to choose any subject from a repository of over 40 clinical presentations based on their individual learning needs.
Study procedures
Students took the OSCE twice during the Year 3 curriculum. The first took place in June 2019 approximately five months after they had attended clinical core clerkship rotations. The second OSCE was taken in February 2020 when the Year 3 curriculum ended. Between the two OSCE rounds, students participated in the self-directed learning course while attending clinical rotations.
To investigate the effectiveness of e-learning intervention, student performance at OSCE tests in Year 3 were assessed using a pre/post comparative format. Student OSCE scores were also compared with national scores to investigate improvements in performances, and student perceptions of the impact of e-learning on their OSCE performances were assessed using a questionnaire. For this purpose, we developed a questionnaire that included 36 items composed of three dimensions. The first dimension addressed demographic information, and the second dimension consisted of 10 items that elicited participants’ perceptions of their experiences of e-learning. The third dimension contained 12 items (adapted from Hung [27]) that assessed student readiness for e-learning and four sub-scales that addressed (a) self-directed learning, (b) learner control, and (c) motivation for learning. We translated the original questionnaire, which was written in English into Korean, as we had experience in medical education research and Korean translation.
Students responded to the statements in the second and third dimensions using a five-point scale, where 1 = “Strongly Disagree,” and 5 = “Strongly Agree.” The questionnaire was self-administered and implemented using an online survey tool in June 2020.
Data collection and ethical considerations
Student OSCE scores consisted of history-taking, physical exams, and patient-doctor relationships were obtained for the first and second tests and were summed to produce total scores with a maximum possible score of 100. Student OSCE scores were compared with those of students at other medical schools who had taken OSCEs administered by a consortium of 18 medical schools in the Seoul metropolitan area.
Questionnaires were administered after obtaining permission from the Institutional Review Board of Inha University School of Medicine (2020-06-036). Also, all methods were carried out in accordance with relevant guidelines and regulations. We provided all participating students with a description of the purpose and methods of the study and stressed their rights regarding voluntary participation and personal confidentiality. Students that agreed to participate in the survey completed the questionnaire online. The survey data were retrieved anonymously from the online survey site.
Data analysis
Student OSCE performances were analyzed using descriptive statistics, and OSCE scores obtained for the first- and second-round tests were compared using the paired t-test. Responses to the questionnaire were analyzed using descriptive statistics. Cronbach’s alpha values were calculated to determine the internal consistency of items. Differences between responses to the survey of students with different backgrounds were analyzed using the independent t-test. Students were divided into two age groups about median age (24.0 years). Correlation coefficients were calculated to establish relationships between student perceptions of e-learning and e-learning readiness. The analysis was performed using SPSS Ver. 25.0, and statistical significance was accepted for p values of < 0.05.