Program competency and assessment
Our simulation program used peer role-play (student to student) focusing on MSK symptoms. Learners had two program competencies: (1) to perform an MSK physical examination as part of a patient’s first medical visit for the stated problem, ensuring patient safety and comfort; and (2) to present their clinical reasoning process for establishing a clinical diagnosis after the outpatient encounter to their supervisor.
The study group included 90 fifth-year female medical students who participated as part of their orthopaedic clinical clerkship rotation (our study group consisted only of female students as the study setting was a women’s medical university). All participants had completed the MSK component of coursework in a classroom in the previous academic year including physical examination, clinical reasoning, and diagnosis. They had been on internal medicine clerkship rotation before the orthopaedic clinical clerkship rotation. Rotations were performed in groups of four or five students.
Students were classified into the simulation group (N = 64) and the non-simulation group as the control group (N = 26). The simulation group was defined as those who participated in a “peer role-play” session. The control group was defined as those who, due to schedule circumstances, did not participate in a “peer role-play” session (figure 1).
In this study, using a Mini-CEX, the students’ supervisor observed them each during an encounter with a first-visit patient at the orthopaedic consultation room, and then rated their performance in different domains at the “peer role-play” session the following day. The Mini-CEX has been widely applied to assess clinical competencies for medical students and residents in a clinical setting [12, 13]. Several studies have demonstrated that Mini-CEX domain scores correlate highly with each other [13, 14, 15]. The Mini-CEX has proven validity as an assessment of clinical skills through observation.
We compared Mini-CEX scores between the simulation group and the control group. The assessment domains in the Mini-CEX were: 1) history taking; 2) physical examination; 3) communication; 4) clinical reasoning and diagnosis; 5) humanity and professionalism; 6) management; and 7) overall clinical competency.
We surveyed the pre-learning status and motivation of participants prior to introducing the program as an option. The content of the questionnaire: the pre-learning status and motivation of participants was decided through discussions with supervisors and researchers in this study. The pre-learning status questionnaire points were 1) experience of watching the standardized educational movie about MSK physical examination before the program, 2) experience of participating in role-playing as an educational opportunity for MSK physical examination during their pre-clinical clerkship rotation, and 3) experience of encountering an MSK patient during their previous rotations in other departments. The motivation questionnaire points were 4) students’ motivation to improve their skills of MSK physical examination (4-point Likert scale), and 5) students’ motivation to improve their clinical reasoning skills (4-point Likert scale).
The simulation group took part in all modules of the program on Day 1 and Day 2. The control group took part in only the second module on Day 2. The program consisted of two modules with two sessions in each module.
On Day 1, the first session of the first module consisted of “peer role-play” for an MSK case (choice of a spine, upper extremity, or lower extremity case), in which the interaction took place between the simulated patient (a student) and the doctor (another student). The student who played the role of the patient did not have a script. The second session included the following structural elements to guide learning: recording the interaction to provide feedback; requiring the student to explain their process of the MSK physical examination, clinical reasoning, and diagnosis; having the supervisor assist the student, as needed, during the interaction; having the supervisor use the mini-CEX to formally assess the student’s performance; having the supervisor provide a debrief and feedback to the student regarding their performance; and requiring the student to self-reflect to prepare for the next module.
On Day 2, the first session of the second module included the following structural learning elements: providing the students with real-life patient information from a patient’s pre-interview sheet. Next, the student took the patient’s history and performed a physical examination of a patient who had MSK-related symptoms in the consultation room of the orthopaedic surgery department. The supervisor observed and assessed the student's performance using mini-CEX. The second session included a debrief of the completed mini-CEX assessment with the student. The physical examination and the clinical reasoning and diagnosis were discussed with the student, and feedback on their oral and written tasks was provided by the supervisor. The student was expected to self-reflect for the next step.
We confirmed that all participants, including students and real-life patients, provided informed consent. This study was approved by the Tokyo Women’s Medical University Ethics Review Board.
Data collection and analysis
The mini-CEX scores of the real-life MSK patient encounter in the second module were compared between the simulation group (N =64) and the control group (N = 26) using the Wilcoxon rank-sum test. The alpha-value is at 0.05. In any event, p values less than the alpha-value are, by definition, “statistically significant.” The answers of the pre-learning status and the motivation to participate prior to the program as the pre-survey were compared between the simulation group and the control group. The pre-learning status was analyzed using Pearson’s chi-square test. The motivation scale of physical examination and the clinical reasoning and diagnosis were analyzed using Fisher’s exact test. All analyses were performed using JMP® Pro 15 (SAS Institute Inc., Cary, NC, USA).