Impact of Simulation-based Learning on the Clinical Competence of Medical Students during Pediatric Clerkships

Impact of Simulation-based Learning on the Clinical Competence of Medical Students during Pediatric Clerkships | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Simulation-based Learning on the Clinical Competence of Medical Students during Pediatric Clerkships Abdelaziz Elamin, Maryam Fuad Ali, Amer Almarabheh This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6722115/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted 10 You are reading this latest preprint version Abstract Background Simulation-based learning (SBL) in medicine includes various methods for training medical students in a safe and adaptable environment. Evidence is accumulating regarding the positive impact of SBL on clinical competence. The study aimed to examine the effect of SBL on the clinical competence of medical students as assessed by their performance at the pediatric end of clerkship examination (PECE). Methods The academic performance of twelve cohorts of year-5 students of the College of Medicine and Health Sciences, Arabian Gulf University, Bahrain, was assessed by their performance on the PECE. The exam consists of three parts: logbook continuous assessment, written test, and clinical exam (OSCE and long case). The study spans six academic years before the adoption of SBL in the pediatric curriculum and six academic years after that. Results The study included 2,251 students,1500 females (66.6%) and 751 males (33.4%). The male-to-female ratio remained consistent over the 12 academic years. The students’ performance in the PECE improves significantly after the SBL (p<0.001). A significant reduction in the failure rate was observed in the post-simulation cohort (2.5%) compared to the pre-simulation cohort (10.2%), and the proportion of students achieving an A-grade increased from 3.2% to 16.0% following the introduction of SBL. Conclusion: The study highlighted the positive impact of SBL in improving medical students' knowledge and clinical competence in pediatrics. medical education academic assessment virtual reality Bahrain Figures Figure 1 Figure 2 Introduction Simulation-based learning (SBL) has become a cornerstone of contemporary medical education, offering a controlled and immersive environment for medical students to hone their clinical, technical, and decision-making skills [ 1 ]. Numerous studies have praised simulation's value in medical sciences (medicine, dentistry, and nursing) undergraduate education, demonstrating its impact on enhancing clinical skills and technical competencies, such as performing clinical procedures, and refining non-technical skills, including communication and decision-making [ 2 – 5 ]. It has also been useful for graduate students and residency programs [ 6 , 7 ]. Several key elements must be in place for simulation-based training to be truly effective. These include clear, well-defined learning objectives, a suitable spacious venue, appropriate equipment, software programs, and supportive technologies [ 8 , 9 ]. Besides skilled and committed instructors, thorough debriefing sessions, constructive feedback, and motivated students eager to engage in hands-on practice. Simulation is not only very valuable for clinical training within the medical education curriculum, but it is also useful in assessing clinical competence. In 1990, George Miller outlined a new model for evaluating clinical competence [ 10 ]. Miller’s pyramid model divides the development of clinical competence into four hierarchical processes (acquisition of knowledge, application of knowledge, clinical skills competency, and clinical performance). He pointed out that clinical skill competency is assessed by examining real patients and simulation that can be incorporated within the Objective Structured Clinical Exam (OSCE) using standardized patients and high-fidelity manikins [ 11 ]. At the College of Medicine and Health Sciences (CMHS) of the Arabian Gulf University (AGU) in Bahrain, a Medical Skills and Simulation Center (MSSC) was established in 2017. Beginning in the academic year 2018–2019, SBL was integrated into major clinical sciences curricula (Pediatrics, Obstetrics & Gynecology, Internal Medicine, and Surgery). Since its implementation, this educational approach has become a core component of the clinical curriculum at CMHS, AGU, reflecting an ongoing commitment to experiential and skills-based learning in clinical sciences education. Before the MSSC, the clinical training of the medical students was augmented by standardized patient encounters and computer-assisted learning through patient case scenarios software. We have examined the effectiveness of that intervention on improving the students’ clinical competence during pediatric and clinical medicine rotations and reported a favorable outcome [ 12 , 13 ]. The AGU, MSSC is fitted with advanced simulation equipment, high-fidelity manikins, and virtual reality software. It features cutting-edge virtual patient platforms, where learners engage with digital avatars in realistic clinical settings. These technologies provide immediate feedback on communication, history taking, physical examination, clinical reasoning, and decision-making, allowing students to repeat tasks and procedures to the tutor's satisfaction, enhancing students’ confidence and competence. The skilled and dedicated instructors’ debriefing before the immersive exercises and tutors’ feedback is essential for achieving the learning objectives. The curriculum at the College of Medicine and Health Sciences (CMHS) of the Arabian Gulf University (AGU) in Bahrain is a six-year blended program organized into three phases [ 14 ]. Phase I, delivered in the first year, primarily consists of subject-based interactive lectures covering cell biology, embryology, histology, biochemistry, genetics, and growth and development. Phase II is a three-year (Years 2–4) problem-based learning course that addresses core basic medical sciences (anatomy and histology, physiology, pathology, immunology, microbiology, and pharmacology) within a clinical context, supplemented by training in a professional skills lab. Phase III (Years 5 and 6) involves clinical hospital bedside training. Since 2018, this phase has been enhanced by training sessions in the MSSC, utilizing high-fidelity manikins, computerized software, standardized patients, and various types of equipment like the one found in hospitals. Year 5 comprises 40 weeks divided into two blocks. Internal medicine spans 20 weeks, while pediatrics and obstetrics & gynecology cover 10 weeks each. Consequently, pediatrics is taught across four clerkship rotations. Students participating in rotations 1 and 2 during semester I attend pediatrics before completing their internal medicine clerkship, which occurs in semester II, while students in rotations 3 and 4 will attend pediatrics after finishing their internal medicine clerkship. The pediatric end of clerkship examination (PECE) includes a written exam (type A MCQ and extended matching questions), a clinical exam (OSCE at the CMHS, and a single long case at the hospital), and a continuous assessment component documented through a logbook. The logbook records attendance at educational activities and hospital on-call duties, observed and performed procedures, case write-ups, and evaluations of students’ attitudes and soft skills by tutors. The weight of these components is as follows: written 35%, clinical 40%, and continuous assessment 25%. To date, no research has examined the impact of SBL on pediatric education in the CMHS, AGU. This study aimed to evaluate the influence of SBL on medical students’ clinical competence as judged by their performance at the PECE. Methods The academic performance of year-5 medical students in the PECE over twelve academic years, from September 2012 to June 2024, comprising six years before and six years following the incorporation of SBL into the pediatric curriculum, was retrospectively analyzed. The two cohorts comprised 2,251 year-5 medical students. The performance metrics used were based on the three components of the end-of-rotation examination: the written exam, the clinical exam, and the continuous assessment. Demographic data, age, and gender were collected for all participants. The detailed examination results of the participants at the PECE in the twelve academic years were obtained from the evaluation and assessment unit of the CMHS, AGU. As fifth-year medical students complete their pediatric rotation in four distinct groups across each academic year, performance outcomes were also compared across these rotation groups and subjected to statistical analysis. Research and Ethics Approval: The research did not include human subjects. The research proposal was approved by the Research and Ethics Committee of the CMHS, AGU (Ref. E23-PI-12-24), the college's dean, and the Students’ Affairs Administration of AGU. Statistical analysis Data were entered into Excel sheets and processed using SPSS software version 29.0 (Chicago, IL, USA). The means and standard deviations were calculated, and the significance level was defined at P < 0.05. Results Of the 2,251 students included in the study, 1,001 (44.5%) were from the pre-simulation period, which includes the academic years 2012–2013 to 2017–2018, while 1,250 students (55.5%) were from the post-simulation period, covering the academic years 2018–2019 to 2023–2024. The difference in the number of students in the two cohorts is due to the increase in the number of students admitted to the CMHS, AGU after 2018. The age of the students ranged from 21 to 24 years (mean 22.4 + 0.97). Males comprised 33.4% of the students and females constituted 66.6%. There was no significant difference in the male/female ratio between the pre- and post-simulation cohorts. The distribution of students across academic years and individual pediatric rotation groups is detailed in Table 1 . Table 2 presents a comparative analysis of the academic performance among students who completed their pediatric rotation before (n = 1001) and after (n = 1250) the integration of simulation-based learning (SBL) in the pediatric curriculum. A statistically significant improvement was observed in the written examination scores, with the mean increasing from 56.88 ± 15 in the pre-simulation group to 71.16 ± 16.85 in the post-simulation group (p < 0.001). Similarly, the mean score for continuous assessment showed a significant increase from 81.37 ± 6.13 to 83.05 ± 7.13 (p < 0.001). Clinical examination scores also improved significantly, rising from 69.06 ± 10.48 to 73.69 ± 9.17 (p < 0.001). Overall academic performance increased by 5.75%, with the mean rising from 69.66 ± 8.13 to 75.41 ± 8.90, also reaching statistical significance (p < 0.001). Table 3 presents a gender-based comparison of academic performance before and after the implementation of simulation-based learning. Both male and female students demonstrated statistically significant improvements across all assessment domains (p < 0.001). The overall performance scores showed an increase in both genders’ scores, with male students improving from 68.27 ± 7.56 to 75.40 ± 8.62 and female students from 70.50 ± 8.35 to 75.41 ± 9.02. The difference was statistically significant (p < 0.001). A comparative analysis of academic performance across the four pediatric rotation groups is presented in Table 4 and illustrated in Fig. 1 . The students assigned to rotations 1 and 2 scored lower marks than the students assigned to rotations 3 and 4. Students in rotation 2 exhibited the lowest mean overall performance score (70.15 ± 8.24). Students assigned to Rotation Groups 3 and 4 demonstrated the highest mean overall performance scores (74.16 ± 9.36 and 73.97 ± 9.03, respectively), with relatively lower variability, indicating more consistent achievement. This observed difference in performance across the rotation groups was statistically significant (P < 0.001). This finding is no wonder because the students come to the pediatrics rotations 3 and 4 after completing 20 weeks of training in internal medicine, which augments their history taking skills and physical examination techniques and improves their knowledge and clinical reasoning. The distribution of the overall academic performance grades, classified into five categories (Fail, Pass, Good, Very Good, and Excellent), which corresponds to the grades F, C, B, B+, and A respectively, was compared between the students who were assessed before and after the implementation of the simulation-based learning. These findings are summarized in Table 5 and visually represented in Fig. 2 . A noticeable reduction in the failure rate was observed in the post-simulation cohort (2.5%) compared to the pre-simulation cohort (10.2%). The difference was statistically significant (p < 0.001). Conversely, the proportion of students achieving an "Excellent" A grade increased markedly following the introduction of simulation-based training, rising from 3.2–16.0% (p < 0.001). Discussion Globally, medical education is shifting toward practical hands-on training and real-time assessment of clinical competence in the workplace. However, applying this method with real patients can sometimes pose risks to patient safety and may raise legal and ethical concerns. Consequently, simulation-based training has become an invaluable alternative [ 15 ]. Thereafter, the utilization of SBL has significantly increased in recent years. This educational approach has proven to be a valuable tool not only for clinical and surgical procedures and time-sensitive resuscitation training in pediatric emergencies, but also for non-procedural areas such as communication skills and decision-making abilities [ 16 – 18 ]. In this study, the integration of SBL strategies into the pediatric clerkship curriculum has demonstrated a statistically significant positive impact on students’ clinical competence and overall academic performance at the PECE. This was reflected in improvements in both written and clinical examination scores. These findings reinforce the growing recognition of SBL as a valuable and effective educational strategy in medical education. The observed benefits align with those reported in several previously published studies, further supporting the incorporation of SBL into undergraduate medical curricula. In a meta-analysis of 15 studies, Lei Y et al. demonstrated that high-fidelity simulation training was associated with a statistically significant improvement in objective knowledge examination scores among nursing students [ 19 ]. Similarly, a study involving emergency medicine residents reported that incorporating high-fidelity simulation into their residency curriculum resulted in a significant enhancement of residents’ clinical performance in real-world settings [ 20 ]. Additionally, a recent survey conducted among 50 medical students who participated in realistic simulation-based learning revealed highly favorable feedback. Most students reported that SBL was a more effective method for achieving learning objectives. An overwhelming number of participants (94%) have indicated that they found the SBL approach more engaging and enjoyable than traditional learning methods [ 21 ]. A previous study from CMHS, AGU examined the influence of SBL structured pre-briefing using concept mapping on clinical competence of 84 year-5 students. It found that SBL Structured pre-briefing significantly enhances medical students’ competency performance, clinical judgment, and perceptions of pre-briefing. It enabled the learners to reflect on their previous experiences and to anticipate the management plan more effectively [ 22 ]. The current study demonstrated that implementing SBL was linked to a marked reduction in the proportion of students receiving a "Fail" rating, accompanied by a significant increase in those achieving an "Excellent" grade. Furthermore, the overall distribution of academic performance shifted notably. In contrast, most students were previously clustered around the "Good" category; the post-simulation cohort showed a clear shift toward higher achievement, with a larger proportion of students falling within the "Very Good" and "Excellent" categories. This suggests a positive shift in the performance curve following the introduction of SBL into the curriculum. A growing number of recent studies have focused on optimizing SBL by exploring strategies to enhance its structure, consistency, and educational impact. Researchers are examining various elements and methods that may improve the effectiveness of SBL. Such interventions include scenario realism, structured debriefing, standardized patients, learner engagement, feedback mechanisms, and opportunities for deliberate practice [ 23 ]. Conclusion The study emphasizes the positive impact of integrating SBL into pediatric education for medical students. These findings advocate for the wider adoption of simulation as a teaching method in other clinical specialties and subspecialties. SBL has the potential to complement and, to some extent, gradually supplant traditional classroom-based instruction and assessment. Declarations Research Ethics Approval : The research adhered to the Helsinki Declaration, which addresses ethical principles for medical research involving human participants. The research proposal was reviewed and approved by the Research and Ethics Committee of the College of Medicine and Health Sciences (CMHS), Arabian Gulf University (AGU) in Bahrain (Ref. E23-PI-12-24). Consent to Participate The consent to participate was deemed unnecessary by the CMHS, AGU Research Review Board. The analysis of the students’ results at the PECE was approved by the University Students' Affairs Unit and the dean of CMHS. The personal information of the students was not collected. Consent for Publication Not applicable. Human Ethics and consent to participate declarations: Not applicable. Clinical trial number : not applicable. Funding : The authors received no funding for the research. Conflict of interest : The authors declare that they have no conflict of interest. Data Availability : The raw data from this study are available upon request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions. Author Contribution Authors Elamin A, and Ali MF. Planned the research project and wrote the manuscript.Author: Almarabheh A: Processed the data and did the statistical analysis. References Alharbi A, Nurfianti A, Mullen RF, McClure JD, Miller WH. The effectiveness of simulation-based learning (SBL) on students’ knowledge and skills in nursing programs: a systematic review. BMC Med Educ. 2024;24:1099. doi.org/10.1186/s12909-024-06080-z . Foucault-Fruchard L, Michelet-Barbotin V, Leichnam A, et al. 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Variables n (%) Distribution before and after the implementation of simulation-based training Before simulation-based training 1001 (44.5) After simulation-based training 1250 (55.5) Distribution across pediatric rotation groups Rotation 1 578 (25.7) Rotation 2 594 (26.4) Rotation 3 550 (24.4) Rotation 4 529 (23.5) Distribution across academic years 2012–2013 137 (6.1) 2013–2014 140 (6.2) 2014–2015 183 (8.1) 2015–2016 185 (8.2) 2016–2017 186 (8.3) 2017–2018 190 (8.4) 2018–2019 186 (8.3) 2019–2020 180 (8.0) 2020–2021 204 (9.1) 2021–2022 217 (9.6) 2022–2023 222 (9.9) 2023–2024 221 (9.8) Values are presented as numbers and percentages. The total number is 2251. Table 2 Analysis of academic performance, before and after simulation-based training (SBT). Type of assessment Before SBT, mean ± SD n = 1001 After SBT, mean ± SD n = 1250 P-value Effect size Written Exam 56.88 ± 15 71.16 ± 16.85 < 0.001 0.890 Clinical Exam 69.06 ± 10.48 73.69 ± 9.17 < 0.001 0.473 Contin. Assessment 81.37 ± 6.13 83.05 ± 7.13 < 0.001 0.254 Overall Performance 69.66 ± 8.13 75.41 ± 8.90 < 0.001 0.671 Values are presented as mean and Standard deviation (SD) Table 3 Academic performance of male and female students, before and after implementation of simulation-based training. Type of assessment Male students P-value Female students P-value Before, SBT mean ± SD n = 374 After SBT mean ± SD n = 377 Before, SBT mean ± SD n = 627 After SBT mean ± SD n = 873 Written Exam 55.54 ± 14.10 71.15 ± 17.13 < 0.001 57.68 ± 15.47 71.17 ± 16.74 < 0.001 Contin. Assessment 81.28 ± 7.45 82.87 ± 6.05 < 0.001 81.36 ± 6.90 83.57 ± 6.16 < 0.001 Clinical Exam 67.07 ± 10.10 73.67 ± 8.46 < 0.001 70.25 ± 10.54 73.69 ± 9.46 < 0.001 Overall Performance 68.27 ± 7.56 75.40 ± 8.62 < 0.001 70.50 ± 8.35 75.41 ± 9.02 < 0.001 Values are presented as mean and Standard deviation (SD) Table 4 Academic performance of the medical students across four pediatric rotation groups. Type of assessment Rotation 1, mean ± SD n = 578 Rotation 2, mean ± SD n = 595 Rotation 3, mean ± SD n = 550 Rotation 4, mean ± SD n = 529 P-value Written Exam 66.84 ± 17.36 60.92 ± 15.48 68.34 ± 18.54 68.68 ± 17.36 < 0.001 Contin. Assessment 82.55 ± 6.13 80.71 ± 6.82 83.53 ± 7.25 82.74 ± 5.96 < 0.001 Clinical Exam 70.60 ± 9.73 70.81 ± 10.30 72.83 ± 10.17 73.50 ± 9.89 < 0.001 Overall Performance 72.37 ± 9.02 70.15 ± 8.24 74.16 ± 9.36 73.97 ± 9.03 < 0.001 Values are presented as mean and Standard deviation (SD) Table 5 Academic performance categories of the students before and after the simulation-based training. Categories Before SBT N (%) n = 1001 After SBT N (%) n = 1250 P-values Fail (F) 102 (10.2) 31 (2.5) < 0.001 Pass (C) 270 (27.0) 186 (14.9) < 0.001 Good (B) 403 (40.2) 371 (29.6) < 0.001 Very good (B+) 194 (19.4) 463 (37.0) < 0.001 Excellent (A) 32 (3.2) 199 (16.0) < 0.001 Values are presented as numbers and percentages. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Oct, 2025 Read the published version in BMC Medical Education → Version 1 posted Editorial decision: Revision requested 21 Jul, 2025 Reviews received at journal 20 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 08 Jul, 2025 Reviewers agreed at journal 07 Jul, 2025 Reviewers invited by journal 24 Jun, 2025 Editor assigned by journal 24 Jun, 2025 Editor invited by journal 03 Jun, 2025 Submission checks completed at journal 03 Jun, 2025 First submitted to journal 03 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6722115","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":475719929,"identity":"554e04ba-28ba-43a0-99dd-82af1358ef69","order_by":0,"name":"Abdelaziz Elamin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAklEQVRIiWNgGAWjYDACCQYDhgcMDDxgzgeImAEDY8MB/FoSoFoYZ5CiBQyYeYjRwj+7eeODhJo6Gfn27sTHNjW1iQ3szdskGHfcwW3JnWPFBgnH2HgYe85uNs45djyxgedYmQTjmWe4HXYjx0wigY2Hh1kid5t0DtuxxAYJoAhj22GcOuRv5Jj/SPgnwcMm/3b7b4t/QC3yb/BrMQDawpDYZsDDI8G7jZmxrQZoCw9+LYZAv0gk9iXwSPDkbpbs7Ttg3MaTVmyReAa3FrnbzRs/fPhWZy/ffnbjhx/f6mT72Q9vvPFxB24t6OAwAxuISiBaAwNDHQlqR8EoGAWjYKQAALdiWEAxn8oAAAAAAElFTkSuQmCC","orcid":"","institution":"Arabian Gulf University","correspondingAuthor":true,"prefix":"","firstName":"Abdelaziz","middleName":"","lastName":"Elamin","suffix":""},{"id":475719930,"identity":"1cab3011-2fbb-485d-b38e-8f992b54653d","order_by":1,"name":"Maryam Fuad Ali","email":"","orcid":"","institution":"Arabian Gulf University","correspondingAuthor":false,"prefix":"","firstName":"Maryam","middleName":"Fuad","lastName":"Ali","suffix":""},{"id":475719931,"identity":"5821b7af-93e2-43c1-bc2d-4c85c7ce1dac","order_by":2,"name":"Amer Almarabheh","email":"","orcid":"","institution":"Arabian Gulf University","correspondingAuthor":false,"prefix":"","firstName":"Amer","middleName":"","lastName":"Almarabheh","suffix":""}],"badges":[],"createdAt":"2025-05-22 07:08:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6722115/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6722115/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-025-07911-3","type":"published","date":"2025-10-02T15:57:35+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85735285,"identity":"f99289a4-7386-4974-8671-ad9160cdebe9","added_by":"auto","created_at":"2025-07-01 07:57:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":23846,"visible":true,"origin":"","legend":"\u003cp\u003eAnalysis of the academic performance of the students (n=2251) across four pediatric rotation groups.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6722115/v1/11d62db6bb7256dfb104c08e.png"},{"id":85735287,"identity":"e60fc665-8163-4cbf-a87d-b799256bdd0b","added_by":"auto","created_at":"2025-07-01 07:57:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16453,"visible":true,"origin":"","legend":"\u003cp\u003eAcademic performance categories of the students, before and after the simulation-based learning.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6722115/v1/9910be217229d0e83a6cfb3f.png"},{"id":92883971,"identity":"df098af5-5909-4832-b499-58ce9115ce3f","added_by":"auto","created_at":"2025-10-06 16:11:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":824621,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6722115/v1/e8487bb5-b797-4364-81bc-7624e8669298.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Impact of Simulation-based Learning on the Clinical Competence of Medical Students during Pediatric Clerkships","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSimulation-based learning (SBL) has become a cornerstone of contemporary medical education, offering a controlled and immersive environment for medical students to hone their clinical, technical, and decision-making skills [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Numerous studies have praised simulation's value in medical sciences (medicine, dentistry, and nursing) undergraduate education, demonstrating its impact on enhancing clinical skills and technical competencies, such as performing clinical procedures, and refining non-technical skills, including communication and decision-making [\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. It has also been useful for graduate students and residency programs [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral key elements must be in place for simulation-based training to be truly effective. These include clear, well-defined learning objectives, a suitable spacious venue, appropriate equipment, software programs, and supportive technologies [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Besides skilled and committed instructors, thorough debriefing sessions, constructive feedback, and motivated students eager to engage in hands-on practice.\u003c/p\u003e \u003cp\u003eSimulation is not only very valuable for clinical training within the medical education curriculum, but it is also useful in assessing clinical competence. In 1990, George Miller outlined a new model for evaluating clinical competence [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Miller\u0026rsquo;s pyramid model divides the development of clinical competence into four hierarchical processes (acquisition of knowledge, application of knowledge, clinical skills competency, and clinical performance). He pointed out that clinical skill competency is assessed by examining real patients and simulation that can be incorporated within the Objective Structured Clinical Exam (OSCE) using standardized patients and high-fidelity manikins [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAt the College of Medicine and Health Sciences (CMHS) of the Arabian Gulf University (AGU) in Bahrain, a Medical Skills and Simulation Center (MSSC) was established in 2017. Beginning in the academic year 2018\u0026ndash;2019, SBL was integrated into major clinical sciences curricula (Pediatrics, Obstetrics \u0026amp; Gynecology, Internal Medicine, and Surgery). Since its implementation, this educational approach has become a core component of the clinical curriculum at CMHS, AGU, reflecting an ongoing commitment to experiential and skills-based learning in clinical sciences education. Before the MSSC, the clinical training of the medical students was augmented by standardized patient encounters and computer-assisted learning through patient case scenarios software. We have examined the effectiveness of that intervention on improving the students\u0026rsquo; clinical competence during pediatric and clinical medicine rotations and reported a favorable outcome [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe AGU, MSSC is fitted with advanced simulation equipment, high-fidelity manikins, and virtual reality software. It features cutting-edge virtual patient platforms, where learners engage with digital avatars in realistic clinical settings. These technologies provide immediate feedback on communication, history taking, physical examination, clinical reasoning, and decision-making, allowing students to repeat tasks and procedures to the tutor's satisfaction, enhancing students\u0026rsquo; confidence and competence. The skilled and dedicated instructors\u0026rsquo; debriefing before the immersive exercises and tutors\u0026rsquo; feedback is essential for achieving the learning objectives.\u003c/p\u003e \u003cp\u003eThe curriculum at the College of Medicine and Health Sciences (CMHS) of the Arabian Gulf University (AGU) in Bahrain is a six-year blended program organized into three phases [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Phase I, delivered in the first year, primarily consists of subject-based interactive lectures covering cell biology, embryology, histology, biochemistry, genetics, and growth and development. Phase II is a three-year (Years 2\u0026ndash;4) problem-based learning course that addresses core basic medical sciences (anatomy and histology, physiology, pathology, immunology, microbiology, and pharmacology) within a clinical context, supplemented by training in a professional skills lab. Phase III (Years 5 and 6) involves clinical hospital bedside training. Since 2018, this phase has been enhanced by training sessions in the MSSC, utilizing high-fidelity manikins, computerized software, standardized patients, and various types of equipment like the one found in hospitals. Year 5 comprises 40 weeks divided into two blocks. Internal medicine spans 20 weeks, while pediatrics and obstetrics \u0026amp; gynecology cover 10 weeks each. Consequently, pediatrics is taught across four clerkship rotations. Students participating in rotations 1 and 2 during semester I attend pediatrics before completing their internal medicine clerkship, which occurs in semester II, while students in rotations 3 and 4 will attend pediatrics after finishing their internal medicine clerkship. The pediatric end of clerkship examination (PECE) includes a written exam (type A MCQ and extended matching questions), a clinical exam (OSCE at the CMHS, and a single long case at the hospital), and a continuous assessment component documented through a logbook. The logbook records attendance at educational activities and hospital on-call duties, observed and performed procedures, case write-ups, and evaluations of students\u0026rsquo; attitudes and soft skills by tutors. The weight of these components is as follows: written 35%, clinical 40%, and continuous assessment 25%. To date, no research has examined the impact of SBL on pediatric education in the CMHS, AGU. This study aimed to evaluate the influence of SBL on medical students\u0026rsquo; clinical competence as judged by their performance at the PECE.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe academic performance of year-5 medical students in the PECE over twelve academic years, from September 2012 to June 2024, comprising six years before and six years following the incorporation of SBL into the pediatric curriculum, was retrospectively analyzed.\u003c/p\u003e \u003cp\u003eThe two cohorts comprised 2,251 year-5 medical students. The performance metrics used were based on the three components of the end-of-rotation examination: the written exam, the clinical exam, and the continuous assessment. Demographic data, age, and gender were collected for all participants. The detailed examination results of the participants at the PECE in the twelve academic years were obtained from the evaluation and assessment unit of the CMHS, AGU.\u003c/p\u003e \u003cp\u003eAs fifth-year medical students complete their pediatric rotation in four distinct groups across each academic year, performance outcomes were also compared across these rotation groups and subjected to statistical analysis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eResearch and Ethics Approval:\u003c/h2\u003e \u003cp\u003eThe research did not include human subjects. The research proposal was approved by the Research and Ethics Committee of the CMHS, AGU (Ref. E23-PI-12-24), the college's dean, and the Students\u0026rsquo; Affairs Administration of AGU.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData were entered into Excel sheets and processed using SPSS software version 29.0 (Chicago, IL, USA). The means and standard deviations were calculated, and the significance level was defined at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 2,251 students included in the study, 1,001 (44.5%) were from the pre-simulation period, which includes the academic years 2012\u0026ndash;2013 to 2017\u0026ndash;2018, while 1,250 students (55.5%) were from the post-simulation period, covering the academic years 2018\u0026ndash;2019 to 2023\u0026ndash;2024. The difference in the number of students in the two cohorts is due to the increase in the number of students admitted to the CMHS, AGU after 2018.\u003c/p\u003e \u003cp\u003eThe age of the students ranged from 21 to 24 years (mean 22.4\u0026thinsp;+\u0026thinsp;0.97). Males comprised 33.4% of the students and females constituted 66.6%. There was no significant difference in the male/female ratio between the pre- and post-simulation cohorts.\u003c/p\u003e \u003cp\u003eThe distribution of students across academic years and individual pediatric rotation groups is detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents a comparative analysis of the academic performance among students who completed their pediatric rotation before (n\u0026thinsp;=\u0026thinsp;1001) and after (n\u0026thinsp;=\u0026thinsp;1250) the integration of simulation-based learning (SBL) in the pediatric curriculum. A statistically significant improvement was observed in the written examination scores, with the mean increasing from 56.88 \u0026plusmn; 15 in the pre-simulation group to 71.16 \u0026plusmn; 16.85 in the post-simulation group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eSimilarly, the mean score for continuous assessment showed a significant increase from 81.37 \u0026plusmn; 6.13 to 83.05 \u0026plusmn; 7.13 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Clinical examination scores also improved significantly, rising from 69.06 \u0026plusmn; 10.48 to 73.69 \u0026plusmn; 9.17 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Overall academic performance increased by 5.75%, with the mean rising from 69.66 \u0026plusmn; 8.13 to 75.41 \u0026plusmn; 8.90, also reaching statistical significance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents a gender-based comparison of academic performance before and after the implementation of simulation-based learning. Both male and female students demonstrated statistically significant improvements across all assessment domains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The overall performance scores showed an increase in both genders\u0026rsquo; scores, with male students improving from 68.27 \u0026plusmn; 7.56 to 75.40 \u0026plusmn; 8.62 and female students from 70.50 \u0026plusmn; 8.35 to 75.41 \u0026plusmn; 9.02. The difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eA comparative analysis of academic performance across the four pediatric rotation groups is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The students assigned to rotations 1 and 2 scored lower marks than the students assigned to rotations 3 and 4. Students in rotation 2 exhibited the lowest mean overall performance score (70.15\u0026thinsp;\u0026plusmn;\u0026thinsp;8.24). Students assigned to Rotation Groups 3 and 4 demonstrated the highest mean overall performance scores (74.16\u0026thinsp;\u0026plusmn;\u0026thinsp;9.36 and 73.97\u0026thinsp;\u0026plusmn;\u0026thinsp;9.03, respectively), with relatively lower variability, indicating more consistent achievement. This observed difference in performance across the rotation groups was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This finding is no wonder because the students come to the pediatrics rotations 3 and 4 after completing 20 weeks of training in internal medicine, which augments their history taking skills and physical examination techniques and improves their knowledge and clinical reasoning.\u003c/p\u003e \u003cp\u003eThe distribution of the overall academic performance grades, classified into five categories (Fail, Pass, Good, Very Good, and Excellent), which corresponds to the grades F, C, B, B+, and A respectively, was compared between the students who were assessed before and after the implementation of the simulation-based learning. These findings are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and visually represented in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. A noticeable reduction in the failure rate was observed in the post-simulation cohort (2.5%) compared to the pre-simulation cohort (10.2%). The difference was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Conversely, the proportion of students achieving an \"Excellent\" A grade increased markedly following the introduction of simulation-based training, rising from 3.2\u0026ndash;16.0% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eGlobally, medical education is shifting toward practical hands-on training and real-time assessment of clinical competence in the workplace. However, applying this method with real patients can sometimes pose risks to patient safety and may raise legal and ethical concerns. Consequently, simulation-based training has become an invaluable alternative [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThereafter, the utilization of SBL has significantly increased in recent years. This educational approach has proven to be a valuable tool not only for clinical and surgical procedures and time-sensitive resuscitation training in pediatric emergencies, but also for non-procedural areas such as communication skills and decision-making abilities [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, the integration of SBL strategies into the pediatric clerkship curriculum has demonstrated a statistically significant positive impact on students\u0026rsquo; clinical competence and overall academic performance at the PECE. This was reflected in improvements in both written and clinical examination scores. These findings reinforce the growing recognition of SBL as a valuable and effective educational strategy in medical education. The observed benefits align with those reported in several previously published studies, further supporting the incorporation of SBL into undergraduate medical curricula. In a meta-analysis of 15 studies, Lei Y et al. demonstrated that high-fidelity simulation training was associated with a statistically significant improvement in objective knowledge examination scores among nursing students [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Similarly, a study involving emergency medicine residents reported that incorporating high-fidelity simulation into their residency curriculum resulted in a significant enhancement of residents\u0026rsquo; clinical performance in real-world settings [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAdditionally, a recent survey conducted among 50 medical students who participated in realistic simulation-based learning revealed highly favorable feedback. Most students reported that SBL was a more effective method for achieving learning objectives. An overwhelming number of participants (94%) have indicated that they found the SBL approach more engaging and enjoyable than traditional learning methods [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eA previous study from CMHS, AGU examined the influence of SBL structured pre-briefing using concept mapping on clinical competence of 84 year-5 students. It found that SBL Structured pre-briefing significantly enhances medical students\u0026rsquo; competency performance, clinical judgment, and perceptions of pre-briefing. It enabled the learners to reflect on their previous experiences and to anticipate the management plan more effectively [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe current study demonstrated that implementing SBL was linked to a marked reduction in the proportion of students receiving a \"Fail\" rating, accompanied by a significant increase in those achieving an \"Excellent\" grade. Furthermore, the overall distribution of academic performance shifted notably. In contrast, most students were previously clustered around the \"Good\" category; the post-simulation cohort showed a clear shift toward higher achievement, with a larger proportion of students falling within the \"Very Good\" and \"Excellent\" categories. This suggests a positive shift in the performance curve following the introduction of SBL into the curriculum.\u003c/p\u003e \u003cp\u003eA growing number of recent studies have focused on optimizing SBL by exploring strategies to enhance its structure, consistency, and educational impact. Researchers are examining various elements and methods that may improve the effectiveness of SBL. Such interventions include scenario realism, structured debriefing, standardized patients, learner engagement, feedback mechanisms, and opportunities for deliberate practice [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study emphasizes the positive impact of integrating SBL into pediatric education for medical students. These findings advocate for the wider adoption of simulation as a teaching method in other clinical specialties and subspecialties. SBL has the potential to complement and, to some extent, gradually supplant traditional classroom-based instruction and assessment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eResearch Ethics Approval\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe research adhered to the Helsinki Declaration, which addresses ethical principles for medical research involving human participants. The research proposal was reviewed and approved by the Research and Ethics Committee of the College of Medicine and Health Sciences (CMHS), Arabian Gulf University (AGU) in Bahrain (Ref. E23-PI-12-24).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe consent to participate was deemed unnecessary by the CMHS, AGU Research Review Board. The analysis of the students\u0026rsquo; results at the PECE was approved by the University Students\u0026apos; Affairs Unit and the dean of CMHS. The personal information of the students was not collected.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHuman Ethics and consent to participate declarations:\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors received no funding for the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe raw data from this study are available upon request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors Elamin A, and Ali MF. Planned the research project and wrote the manuscript.Author: Almarabheh A: Processed the data and did the statistical analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlharbi A, Nurfianti A, Mullen RF, McClure JD, Miller WH. The effectiveness of simulation-based learning (SBL) on students\u0026rsquo; knowledge and skills in nursing programs: a systematic review. 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J Family Community Med. 2010;17(1):35\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4103/1319-1683.68787\u003c/span\u003e\u003cspan address=\"10.4103/1319-1683.68787\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of the students across academic years and individual pediatric rotation groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution before and after the implementation of simulation-based training\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBefore simulation-based training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1001 (44.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter simulation-based training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1250 (55.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution across pediatric rotation groups\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e578 (25.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e594 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e550 (24.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRotation 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e529 (23.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDistribution across academic years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2012\u0026ndash;2013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e137 (6.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2013\u0026ndash;2014\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e140 (6.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2014\u0026ndash;2015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e183 (8.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2015\u0026ndash;2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e185 (8.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2016\u0026ndash;2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2017\u0026ndash;2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e190 (8.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2018\u0026ndash;2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e186 (8.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u0026ndash;2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e180 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u0026ndash;2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (9.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u0026ndash;2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e217 (9.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2022\u0026ndash;2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2023\u0026ndash;2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e221 (9.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as numbers and percentages. The total number is 2251.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of academic performance, before and after simulation-based training (SBT).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore SBT, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1001\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter SBT, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1250\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEffect size\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWritten Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.88 \u0026plusmn; 15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.16 \u0026plusmn; 16.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.890\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.06 \u0026plusmn; 10.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.69 \u0026plusmn; 9.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.473\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContin. Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.37 \u0026plusmn; 6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.05 \u0026plusmn; 7.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.254\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69.66 \u0026plusmn; 8.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.41 \u0026plusmn; 8.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as mean and Standard deviation (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcademic performance of male and female students, before and after implementation of simulation-based training.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eType of assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eMale students\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eFemale students\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore, SBT mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;374\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter SBT mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;377\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBefore, SBT mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;627\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAfter SBT\u003c/p\u003e \u003cp\u003emean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;873\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWritten Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55.54 \u0026plusmn; 14.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.15 \u0026plusmn; 17.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.68 \u0026plusmn; 15.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.17 \u0026plusmn; 16.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContin. Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.28 \u0026plusmn; 7.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.87 \u0026plusmn; 6.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e81.36 \u0026plusmn; 6.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.57 \u0026plusmn; 6.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.07 \u0026plusmn; 10.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73.67 \u0026plusmn; 8.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.25 \u0026plusmn; 10.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73.69 \u0026plusmn; 9.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.27 \u0026plusmn; 7.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.40 \u0026plusmn; 8.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.50 \u0026plusmn; 8.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e75.41 \u0026plusmn; 9.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as mean and Standard deviation (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcademic performance of the medical students across four pediatric rotation groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType of assessment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRotation 1, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;578\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRotation 2, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;595\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRotation 3, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;550\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRotation 4, mean \u0026plusmn; SD\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;529\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWritten Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.84 \u0026plusmn; 17.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.92 \u0026plusmn; 15.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e68.34 \u0026plusmn; 18.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.68 \u0026plusmn; 17.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContin. Assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e82.55 \u0026plusmn; 6.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.71 \u0026plusmn; 6.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e83.53 \u0026plusmn; 7.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.74 \u0026plusmn; 5.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical Exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e70.60 \u0026plusmn; 9.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.81 \u0026plusmn; 10.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e72.83 \u0026plusmn; 10.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.50 \u0026plusmn; 9.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72.37 \u0026plusmn; 9.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.15 \u0026plusmn; 8.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e74.16 \u0026plusmn; 9.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73.97 \u0026plusmn; 9.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as mean and Standard deviation (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAcademic performance categories of the students before and after the simulation-based training.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategories\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore SBT\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1001\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter SBT\u003c/p\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1250\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP-values\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFail (F)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e102 (10.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePass (C)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e270 (27.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186 (14.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood (B)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e403 (40.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e371 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery good (B+)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e194 (19.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e463 (37.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExcellent (A)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e199 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eValues are presented as numbers and percentages.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"medical education, academic assessment, virtual reality, Bahrain","lastPublishedDoi":"10.21203/rs.3.rs-6722115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6722115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSimulation-based learning (SBL) in medicine includes various methods for training medical students in a safe and adaptable environment. Evidence is accumulating regarding the positive impact of SBL on clinical competence. The study aimed to examine the effect of SBL on the clinical competence of medical students as assessed by their performance at the pediatric end of clerkship examination (PECE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe academic performance of twelve cohorts of year-5 students of the College of Medicine and Health Sciences, Arabian Gulf University, Bahrain, was assessed by their performance on the PECE. The exam consists of three parts: logbook continuous assessment, written test, and clinical exam (OSCE and long case). The study spans six academic years before the adoption of SBL in the pediatric curriculum and six academic years after that.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study included 2,251 students,1500 females (66.6%) and 751 males (33.4%). The male-to-female ratio remained consistent over the 12 academic years. The students’ performance in the PECE improves significantly after the SBL (p\u0026lt;0.001). A significant reduction in the failure rate was observed in the post-simulation cohort (2.5%) compared to the pre-simulation cohort (10.2%), and the proportion of students achieving an A-grade increased from 3.2% to 16.0% following the introduction of SBL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study highlighted the positive impact of SBL in improving medical students' knowledge and clinical competence in pediatrics.\u003c/p\u003e","manuscriptTitle":"Impact of Simulation-based Learning on the Clinical Competence of Medical Students during Pediatric Clerkships","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 07:57:20","doi":"10.21203/rs.3.rs-6722115/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-21T08:18:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T16:52:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T07:07:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60440774852504293771765298796305077522","date":"2025-07-08T05:01:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254230149012984730937174359199487398395","date":"2025-07-07T19:10:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-24T11:15:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-24T11:00:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-03T11:12:28+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-03T07:41:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-06-03T07:38:37+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1a436c5e-67eb-497c-882b-a1675291872e","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-06T16:06:22+00:00","versionOfRecord":{"articleIdentity":"rs-6722115","link":"https://doi.org/10.1186/s12909-025-07911-3","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2025-10-02 15:57:35","publishedOnDateReadable":"October 2nd, 2025"},"versionCreatedAt":"2025-07-01 07:57:20","video":"","vorDoi":"10.1186/s12909-025-07911-3","vorDoiUrl":"https://doi.org/10.1186/s12909-025-07911-3","workflowStages":[]},"version":"v1","identity":"rs-6722115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6722115","identity":"rs-6722115","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}