We have provided evidence of the effectiveness of simulation-based education to improve the skills of students for performing an MSK physical examination. We used peer role-play as a simulation, with students assuming the role of a patient with MSK symptoms in a clinical clerkship setting.
A meta-analysis had reported the effectiveness of simulation-based medical education (SBME) for improving clinical skills among medical learners . Another study reported on the effectiveness of SBME in improving diagnostic skills for rheumatoid arthritis and osteoarthritis . Yet another study showed that medical students had difficulty in improving their MSK physical examination skills during regular clinical clerkship activities. However, small group interactive clinical skills courses, with multi-source feedback provided to students, produced considerable improvement in clinical skills after several months . These findings underline the importance of clinical skills laboratory sessions, including simulation-based opportunities, in improving skills and clinical reasoning. In this study, we showed in the short term that SBME could be effective in enhancing learners’ skills at MSK physical examination during clinical clerkships, and that the mini-CEX could be a timely and effective workplace-based assessment tool. Of note with regard to SBME, a review article reported no significant difference in learning between high- and low-fidelity simulation . That study supports our use of low-fidelity simulation, namely peer role-play, to improve physical examination skills. Our results suggest that peer role-play is a valid form of low-fidelity simulation education. On the other hand, our results did not demonstrate an improvement in competency for Clinical reasoning and diagnosis. One reason for this might be that the role-playing was limited achieving clinical reasoning competency for the real-life patient in a clinical setting by its low validity and reliability. We addressed this issue, in part, by providing an ad-lib encounter based on MSK cases without a script. However, a recent study indicated the importance of using standardized patients to enhance clinical skills in MSK assessment when the timeframe for laboratory-based practice is limited . It is important to note that while the use of SBME to enhance clinical skills has yet to be fully justified, simulation-based education has been shown to be a valuable and effective approach for teaching communication skills during a patient encounter. However, there is limited evidence on how this translates to patient outcomes, and no indication of the economic benefit from this type of training compared to other methods . There is a need for future research to consider more fully the optimal format for clinical-based education and its full role in medical education.
The peer role-play simulation used in this study was implemented by one faculty member who is a specialist of orthopaedic and health profession education. This helped to ensure the consistency and reliability of the education and assessment among participants. However, this approach is not sustainable, as it places a high demand on one individual. Team teaching using an OSCE format would provide a more sustainable approach for clinical skills training in a structured program of medical education. Battistone used OSCE stations developed by two orthopaedic surgeons, two rheumatologists, and a primary care provider with orthopaedic experience . Other studies have recommended the use of near-peer teaching in medical student education, particularly for hands-on skills . One possible way to blend these two approaches might be to involve patients as educators in sessions on MSK physical examination. In the same way, including physician tutors to work with students on clinical reasoning, based on outcomes for History and Physical examination, can enhance student learning. This strategy would allow physicians to use their teaching time more efficiently and, possibly, increase students’ opportunity to become comfortable with basic skills in MSK physical examination, clinical reasoning and diagnosis .
Feedback is an important component of workplace-based assessments of student performance in clinical practice. In our study, for the sake of consistency and to ensure that the feedback provided was comprehensive, feedback was provided by the same supervisor for all the students and it was based on the mini-CEX. A previous study has demonstrated the effectiveness of using the mini-CEX to improve student skills during their 3-year clerkship by providing multiple repeated opportunities for feedback on specific clinical tasks . Certainly, in our study, the objectivity of assessment would have been increased if there had been two or more assessors. However, increasing the number of assessors with sufficient experience is challenging, considering the limitations of human resources in the workplace (hospitals, clinics, and educational programs). We have to note the low-to-moderate reliability of the mini-CEX, with between-rater variability being the greatest source of error. This is particularly true if assessments are conducted by both attending physicians and residents, since residents provide higher scores, on average, than faculty . In our study, we were able to assess students’ performance at the workplace using the mini-CEX and timely and formative feedback on the outpatient encounter from a reliable, experienced supervisor. Despite any variability in the mini-CEX in general, this assessment does provide the opportunity for repeated reflection on the formative feedback provided by the supervisor, as well as the students’ self-reflection on their performance on each dimension of the encounter. For feedback effectiveness, one study has suggested that supervisors of clinical education were prepared to comprehend every factor influencing feedback on mini-CEX to improve the students’ learning response . This study suggests that in peer role-playing, assessment and formative feedback from an experienced supervisor, using the mini-CEX, and student self-reflection effectively enhanced clinical skills, especially the physical examination of an outpatient with symptoms of MSK.