The peculiarity of medical education is the integration of learning with practical application in the hospital setting (10). In clerkships, students are assigned to various departments, including internal medicine, surgical disciplines, pediatrics and emergency medicine. They acquire clinical knowledge by shadowing and assisting residential physicians in daily practice, primary patient care, bedside procedures, daily record writing and case presentations (11). The pandemic challenged the educational and healthcare system worldwide. During COVID-19, hospital clerkships for medical students were cancelled, making it difficult to collect practical experience.
Teaching hospitals developed strategies in response to the pandemic, first of all the establishment of online learning platforms (9). Virtual education played a central role in mitigating the impact of this pandemic on the educational process by providing an interactive communication platform (12).
The aim of this retrospective analysis was to investigate how students performed in surgical OSCE before, during and after pandemic. The focus was put on general and visceral surgery. The case station with complete abdominal examination was the unique station which was significantly better performed by the students before and after COVID-19 in comparison to the pandemic. Most students had difficulties completing the abdominal examination in the correct sequence, starting from inspection, through auscultation, percussion and palpation. Often, the students failed to initiate the examination a distance away from the point of maximal pain. This is something completely obvious if someone is practiced in hands-on abdominal examination, but not if this is learned only theoretically without having the possibility to practice on a real patient with real pain. Also, simulation is, in this case, not as effective as a real patient. Initiating the examination at the point of highest pain is associated with patient initiated cessation of examination and thus incomplete assessment and diagnosis, knowledge that would be gained during hands-on training in the hospital, either directly or indirectly through observation of others. Modifications to standardized online learning modalities which include these errors in video format could help reduce these issues during the exam and more importantly, early in the physicians practice.
In the suturing station, student performance was higher during the COVID-19 pandemic. A possible explanation for this could be that students had additional time to self practice with suturing on skin model or even at home on self made models. It is also possible that intrinsic bias is present given that this station was monitored / graded by medical students who changed with every exam cycle, thus limiting assessment reproducibility and consistency.
Students performed better before and after pandemic when explaining a simple surgical procedure (open/laparoscopic inguinal hernia repair and laparoscopic cholecystectomy) than students receiving a complicated one (colon surgery). Before and after COVID-19, medical students had the opportunity to be present within the operating room during a variety of procedures. Senior surgeons working in concert with surgical residents allows for greater detail in description of the procedure, regardless of complexity, increasing the learning opportunities for all trainees present, residents and students alike. During the pandemic, students were not afforded these opportunities for in person learning. Likewise, complex cases are often intricate, with many steps, requiring repetition of observation and in different contexts and patients. Online learning may have failed to provide the variety and context necessary to prepare students for the exam.
The opposite results were observed with the surgical case, where students performed better before and after the pandemic when receiving the complicated case than the simple one. Presence within the visceral surgical ward would have provided students with multiple opportunities to practice analysis of these cases. For example, lower gastrointestinal bleeding and acute diverticulitis are often treated somewhat conservatively, knowledge which would have again been obtained through routine rounds with physicians.
By reporting all score to a minimal common multiple of 40, the lowest score of all stations in all OSCE was achieved by the students at the surgical case stations during pandemic, marking again that bedside teaching is an important part of the medical university curriculum, which even in a pandemic, should not be stopped. Limitations of this study include missing information about the semester in which the students took the examination (6th or 7th). Later in the program of study could have affected their performance on the exam where students could have better integrated the knowledge received. Likewise, the ward in which clerkships were completed were not consistent (visceral vs. vascular vs. traumatology wards). Rotations within the visceral ward no doubt would improve their performance on such an exam, where their exposure to these types of procedures would have been more frequent and in depth. As noted earlier, within the suturing station, evaluators could have impacted the overall results with senior students rather than practicing physicians conducting the examinations and providing their graded assessments. Consistency in grading could be difficult given the larger number of evaluators, their limited level of experience, and the constant changing of these evaluators with each cycle of examinations (13). A last limitation noted by the authors is in the consistency of the examination itself, in that the same stations provided cases of varying degrees of difficulty to students during the same OSCE exam.
Future studies should be focused on assessing if our findings using the three OSCE visceral stations, i.e. that students performed worse in stations where a previous bed-side teaching was required, can be generalized to the other nine OSCE stations, with some of them related to clinical skills (e.g. repairing a drainage) and practical knowledge which assumes the student has already had practice with real patients.