Deliberate Practice: A Framework for boosting pre-clerkship clinical skills

Deliberate Practice: A Framework for boosting pre-clerkship clinical skills | 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 Deliberate Practice: A Framework for boosting pre-clerkship clinical skills Min Xu, Hongmei Shi, Youren Zhang, Hong Lei, Miao Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4888330/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Clinical skills performance is a core competence for medical students, yet many pre-clerkship students encounter significant challenges in applying clinical skills effectively during their transition to clinical rotations. This study aims to explore effective training frameworks and pedagogical approaches that enhance clinical skills performance, thereby facilitating the transition from preclinical to clinical clerkship and fostering the development of clinical competence. Methods A total of 157 pre-clerkship students graded in the 4th year were enrolled in this study. All the students underwent two-week enhanced performance training in clinical skills which focusing on medical history-taking, physical examination, and essential procedural skills. Two competence-based evaluations in the form of objective structured clinical examination (OSCE) were implemented before (OSCE-2) and after (OSCE-3) the enhanced performance training for the students. Additionally, OSCE scores of clinical diagnostic curricula (OSCE-1) which conducted two years ago were referred for comparison. Results The medical history-taking performance of pre-clerkship students demonstrated fine skills retention in the pre-training OSCE examination [79.50 (9.50) in OSCE-1 vs 79.50 (9.50) in OSCE-2, q = 1.767, p = 0.424]. However, both performance of physical examination [95.10 (5.80) in OSCE-1 vs 85.00 (8.00) in OSCE-2, q = 15.840, p < 0.001]and essential procedural skills [93.00 (10.00) in OSCE-1 vs 88.00 (14.00) in OSCE-2, q = 5.284, p < 0.001] showed a significant decay with time. Skills performance in medical history-taking [83.50 (7.25) in OSCE-3 vs 79.50 (9.50) in OSCE-2, q = 7.028, p < 0.001], physical examination [90.25 (7.38) in OSCE-3 vs 85.00 (8.00) in OSCE-2, q = 7.430, p < 0.001], and essential procedural skills [95.00 (4.63) in OSCE-3 vs 88.00 (14.00) in OSCE-2, q = 9.247, p < 0.001] all showed significant improvement after the enhanced skills performance training. Conclusion The enhanced clinical skills performance training curriculum contributed to facilitate the transition from preclinical to clinical clerkship with improving skills performance. The aligned framework of deliberate practice and advanced teaching modalities showed significant effectiveness in the enhanced clinical skills performance training for pre-clerkship students, which providing reference to peers for best practices in evidence-based medicine education. clinical skills medical history-taking physical examination procedural skills pre-clerkship clinical competence deliberate practice Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Clinical skills performance is a core competence for medical students. In traditional medical educational program, clinical skills performance training is mainly implemented during the clinical clerkship, while the theoretical and apprenticeship learning of medicine were mainly carried out in pre-clinical period for students[ 1 , 2 ]. Increasing evidence and experience from medical educators indicated that pre-clerkship students confronted difficulties and often felt unprepared when transiting from didactic learning to clinical rotations[ 3 – 5 ]. In real-world clinical settings, students have been expected to take medical histories, examine patients, or perform certain essential procedural tasks, while patients desire safe and harm-free expert care. Competence-based clinical skills performance training is required to ensure enough clinical practice for first-year clerkship students as well as the safety of individual patients[ 6 ]. Deliberate practice has been proved for its effectiveness in clinical skills training [ 7 – 9 ]. Taking Skills Boot Camp as example, it has been demonstrated that enhanced skills training contributes to help residents to attain clinical competence when performing on patients[ 10 , 11 ]. However, there is a lack of comprehensive clinical skills training curriculum in pre-clerkship period. Therefore, we instituted a two-week competence-oriented enhanced clinical skills performance training curriculum under the frameworks of deliberate practice. This study is aimed at exploring effective teaching frameworks and modalities to deliver high-quality clinical skills performance training for pre-clerkship students, which also provide evidence for decision-making of medical education policy. METHODS Participants and settings A total of 157 medical undergraduates graded in the 4th academic year from the 2nd affiliated clinical college of Wuhan University, China were enrolled in this study. The enrolled students previously received medical education under the same teaching syllabus and requirements. Instructors with medical faculty qualification formed the responsible teaching staff of the enhanced clinical skills performance training curriculum. Each enhanced performance training session was undertaken by the same instructor during the curriculum. An instructor/student ration of no more than 1:10 was required to assure proper assistance and supervision in the performance training scenarios. Design of the enhanced clinical skills performance training curriculum The enhanced clinical skills performance training curriculum focused on medical history-taking, physical examination, and essential procedural skills. Twenty-five simulated performance training sessions were imparted for undergraduates at the start of their clinical clerkship. Before the start of each performance training session, online delivery of review materials for each clinical skill was provided to students. These materials included didactic materials, audio/visual resources, and various reference materials such as electronic textbooks, procedural manuals, and reputable internet websites. The enhanced clinical skills performance training employed a simulation-based pedagogical approach within simulated clinical scenarios, adhering to a structured six-step LSPPDM teaching process as follows: learn, see, practice, prove, do, and maintain[ 12 ]. All students were required to undergo pre- and post-training competence assessment through an Objective Structured Clinical Examination (OSCE)[ 13 ]. The following provides a detailed description of the concrete implementation of enhanced clinical skills performance training in medical history-taking, physical examination, and essential procedural skills. – Procedures of enhanced medical history-taking training Enhanced clinical skills performance training of medical history-taking was implemented utilizing a self-developed Standard Patients (SPs) virtual medical video-interview system. SPs were recruited and trained by the Standard Patients Training Association of the 2nd affiliated clinical college, Wuhan University. SPs with training qualifications will be included in the virtual medical video-interview system. A symptom-oriented case library with scoring criteria for evaluating medical history-taking skills, was developed to synchronize with the SPs virtual medical video-interview system. Students conducted medical video-interviews with SPs using cases which randomly assigned. The instructor scored students’ video-recorded medical history-taking performances according to the scoring criteria accessible through educator’s portal of the Standard Patients (SPs) virtual medical video-interview system, and provided specific feedback to help students identify their strengths and areas for improvement. – Procedures of enhanced physical examination training Four simulated clinical scenarios were designed for physical examination training sessions, each corresponding to the examinations of the thoracic, cardiac, abdominal, and neurological systems. – Procedures of essential procedural skills training Essential procedural skills training imparted twenty simulated training sessions, each focusing on a different essential procedural skill. The involved essential procedural skills included the following items: thoracentesis, abdominocentesis, lumbar puncture, bone marrow puncture, Sengstaken-Blakemore tube placement, nasogastric intubation, urethral catheterization, adult cardiopulmonary resuscitation, defibrillation and synchronized cardioversion, artery puncture and blood gas analysis, venous puncture and transfusion, and fundamental surgical skills which included surgical scrubbing, gowning and gloving, surgical area disinfection and clothing, incision and drainage, sutures and ligaturing, hemostasis, dressing change and suture removal. Additionally, first-aid skills for trauma including wound debridement and bandaging, handling of suspected spinal injuries, fixation of extremities fracture, sputum suction and choking-Heimlich maneuver, oxygen therapy. Finally, donning and doffing personal protective equipment, such as isolation gown and protective suits, were also included in the procedural skills training curriculum. Outcome measures In the OSCE’s assessment, all students were required to randomly select the medical history-taking, physical examination, and the procedural task they had to perform as they progressed through the examination. Clinical skills performance scores in medical history-taking, physical examination and a procedural skill were analyzed from the pre- (OSCE-2) and post-training OSCE assessments (OSCE-3). Furthermore, The OSCE final examination scores from the diagnostic skills curriculum (OSCE-1), administered to the same cohort of students two years ago, were also referred in the analysis. Statistical analysis Data was analyzed using R version 4.4.1. Continuous variables in the study were expressed as median (with interquartile ranges, IQRs) due to a non-normal distribution of data. The Friedman test was applied to perform comparisons for the medians of students’ performance in medical history-taking, physical examination, and a procedural skill across the three OSCE examinations. Nemenyi post hoc comparisons were used to assess differences among parameters of medical history-taking, physical examination, and a procedural skill across the three OSCE examinations. Statistical significance was defined as a two-tailed p-value of less than 0.05. RESULTS 1. Pre-clerkship students’ skills performance in medical history-taking As shown in Table 1 , pre-clerkship students’ skills performance in medical history-taking during the pre-training OSCE assessment (OSCE-2) showed no significant difference compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1) [79.50(9.50) in OSCE-1 vs 79.50(9.50) in OSCE-2, q = 1.767, p = 0.424]. However, significant improvement of skills performance in medical history-taking was observed during the post-training OSCE assessment (OSCE-3), compared to their medical history-taking skills performance in OSCE-2 [83.50 (7.25) in OSCE-3 vs 79.50 (9.50) in OSCE-2, q = 7.028, p < 0.001]. As illustrated in Fig. 1 , the data distribution revealed that there were more high-scoring students in the post-training OSCE assessment (OSCE-3). 2. Pre-clerkship students’ skills performance in physical examination, and essential procedural skills As shown in Table 1 , pre-clerkship students’ skills performance in physical examination and essential procedural skills declined significantly during the pre-training OSCE assessment (OSCE-2), compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1) [95.10 (5.80) in OSCE-1 vs 85.00 (8.00) in OSCE-2, q = 15.840, p < 0.001]. However, significant improvement of skills performance in physical examination skills was revealed during the post-training OSCE assessment (OSCE-3), compared to their skills performance in pre-training OSCE assessment (OSCE-2) [90.25 (7.38) in OSCE-3 vs 85.00 (8.00) in OSCE-2, q = 7.430, p < 0.001]. Similar significant improvement of essential procedural skills performance was observed between the pre-training OSCE assessment (OSCE-2) and the post-training OSCE assessment (OSCE-3) [95.00 (4.63) in OSCE-3 vs 88.00 (14.00) in OSCE-2, q = 9.247, p < 0.001]. As illustrated in Fig. 2 and Fig. 3 , the data distribution revealed that there were fewer students in the lower score brackets after completing the enhanced clinical skills performance training curriculum. Table 1 Pre-clerkship students’ clinical skills performance in OSCE assessments clinical skills performance median (IQR) Friedman test χ² p Pairwise Comparison Nemenyi test q value, and p* OSCE-1 OSCE-2 OSCE-3 medical history-taking OSCE-1 79.50(9.50) 27.802 < 0.001 NA 1.767, p* =0.424 5.261, p *<0.001 OSCE-2 79.50(9.50) NA 7.028, p* <0.001 OSCE-3 83.50(7.25) NA physical examination OSCE-1 95.10(5.80) 126.880 < 0.001 NA 15.840, p *<0.001 8.410, p *<0.001 OSCE-2 85.00(8.00) NA 7.430, p *<0.001 OSCE-3 90.25(7.38) NA essential procedural skills OSCE-1 93.00(10.00) 44.995 < 0.001 NA 5.284, p *<0.001 3.963, p *=0.014 OSCE-2 88.00(14.00) NA 9.247, p *<0.001 OSCE-3 95.00(4.63) NA Note: NA = not applicable. p values were calculated with the Friedman test. p * values were assessed with the post hoc Nemenyi test. DISCUSSION In this study, competence-oriented enhanced clinical skills training curriculum was designed to investigate its effectiveness on clinical skills competence in pre-clerkship students. We found that clinical skills performance of pre-clerkship students tended to decay with time, but then rebounded after the refresher training. These findings demonstrated that a structured program of deliberate practice in clinical skills contributed to improve clinical skills competence of pre-clerkship students. Medical history-taking and physical examination skills are essential components of clinical competence in medical education, which requiring a systematic and patient-centered approach. However, it has been repeatedly reported that medical students or first-year residents showed a lack of confidence and with little preparation or formal instruction when suddenly were asked to take medical history and examine patients in real-world clerkship [ 3 – 5 , 14 ]. In our study, physical examination skills of pre-clerkship students decayed significantly in the pre-training OSCE assessment (OSCE-2), compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1). Both medical history-taking and physical examination skills performance showed significant improvement after the refresher training. These findings are line with the educational philosophy of deliberate practice. Clinical skills with limited opportunity for practice present natural skill degradation without refresher training[ 15 ]. Deliberate practice is characterized of highly structured training activity oriented to improve specific technical skills. It has been confirmed for effective skills training, underling repetitive practice and formative feedback [ 7 , 16 , 17 ]. In this study, our curriculum team made several targeted methodological improvements in the enhanced skills performance training of medical history-taking and physical examination. First, the implementation of self-developed Standard Patients (SPs) virtual medical video-interview system offered more opportunities of deliberate practice with videorecording feedback for students. This innovative training approach has addressed the specific limitations in medical history-taking instruction, including a shortage of educational manpower, stringent time constraints, budgetary restrictions, and limited resources[ 14 ]. The remarkable improvement of medical history-taking skills performance was also attributed to the establishment of a structured educational framework, with standardized qualification of SPs behaviorism, symptom-oriented case library and standardized scoring criteria for medical interviews feedback[ 2 , 18 , 19 ]. All these refinements ensure the standardization and homogeneity of the training in medical history-taking. Second, in our enhanced physical examination skills performance training, a “core + clusters” strategy was applied, integrating symptom-driven clusters of additional medical histories into the core curriculum[ 20 ]. Students conducted repetitive practice on simulated human models incorporating clinical reasoning in four different clinical scenarios, including cardiovascular, breast, abdominal, neurological, and spinal physical exam maneuvers. The educational framework of deliberate practice was instrumental in the significant improvement in physical examination skills performance, with clinical reasoning and critical thinking being another key contributor [ 20 , 21 ]. The present study also observed similar essential procedural skills decay with time followed by significant improvement of procedural skills performance after the enhanced training. This finding again confirmed the effectiveness of deliberate practice in medical procedural skills training, which contributing to consolidate learning and improve procedural skill performance through constructive practice repetition and formative feedback[ 2 , 7 , 17 ]. Additionally, the LSPPDM teaching model also played an important role in the significant improvement of essential procedural skills performance[ 12 ]. The pedagogical frame of “learn, see, practice, prove, do, maintain” (LSPPDM) emphasizes the importance of a structured but step-by-step approach to learning and maintaining procedural skills in medicine[ 12 ]. Our data demonstrated its effectiveness in training pre-clerkship students to perform procedural procedures competently. In terms of the comprehensive feedback for procedural skills performance, both teacher feedback and students’ peer feedback were adopted in the simulated skills performance training process. Previous studies have showed that peer feedback contributed to improve learning outcomes and confidence[ 2 , 22 , 23 ]. During the process of deliberate practice, it is important to involve observing students to remain attentive and learn from each other. The strategy of offering peer feedback from observing students facilitated greater students’ engagement and motivation during the enhanced training of essential procedural skills[ 23 , 24 ]. However, this observed influence of observing students’ peer feedback is proposed from the authors’ experience. The impact of peer observation and feedback on procedural skills acquisition in the pedagogical frame of this study needs further investigation. There are several limitations of this study. First, due to the limited time in the practice session of each training item, we did not conduct a cross-design to ensure equal deliberate practice frequency of each participant. Second, confined to the educational schema of clinical medicine, the time intervals of clinical skills performance in three OSCE assessments were not the same, we could not distinguish the short-term refresher training effects from long-term retention. Given the above limitations, studies exploring the impact of deliberate practice refresher frequency and to identify the optimal timing for preventing clinical skills decay after the enhanced training need to be further investigated. Nevertheless, we remain committed to refining the curriculum design of clinical skills performance enhancement program. CONCLUSIONS The enhanced clinical skills performance training under the framework of deliberate practice in pre-clerkship students contributed to the improvement of clinical skills performance. Strategies facilitating the transition from preclinical to clinical training are crucial for ensuring clinical skills competence in pre-clerkship students. Effective teaching modalities and advanced methodologies of the present study served as references to peers for best practices in evidence-based medicine education. Declarations Ethics approval and consent to participate This study was approved by ethics committee of Zhongnan Hospital, Wuhan University, and informed consent was obtained from all enrolled participants.The ethical approval number is No.2023030k. Consent for publication All authors have approved the manuscript for publication. Availability of data and materials Data are incorporated into the article. Competing interests The authors declare no competing interests. Authors' information (optional) 1 Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan 430071, China 2 School of Public Health, Wuhan University, Wuhan 430071, China 3 Teaching Affair Office, Zhongnan Hospital of Wuhan University, Wuhan 430071, China Correspondence: Miao Yang; email: [email protected] Funding Wuhan University’s Residency Training Teaching Research Project, Innovative mobile App-based heart auscultation skills training platform development (2024011); Hubei Province Higher Education Association Project, Development and application of an online medical history-taking platform in the era of new medical science (2023XC072); Ministry of Education Industry-Academia-Research Project, Future professional competency enhancement for medical students (230901449064603); Wuhan University’s Undergraduate Education Quality Comprehensive Reform Project, Pioneering career competence-based skill assessment models for medical interns (2024-32-10). Author Contribution Min Xu managed the curriculum’s execution and ensured its quality, undertook data collection, and wrote the original draft. Hongmei Shi was engaged in the implementation of the curriculum. Youren Zhang was responsible for data statistical analysis. Hong Lei was engaged in the curriculum’s implementation and provided supervision. Miao Yang was responsible for the curriculum’s implementation and administrative tasks. All authors reviewed the manuscript. Acknowledgements Thanks to the dedicated teaching staff and engaged students of the 2nd affiliated clinical college of Wuhan University, China. Appreciation is extended for the contributions made in the organization, implementation, and management of this enhanced clinical skills performance training curriculum. References Lofaso DP, DeBlieux PM, DiCarlo RP, Hilton C, Yang T, Chauvin SW. Design and effectiveness of a required pre-clinical simulation-based curriculum for fundamental clinical skills and procedures. 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J Gen Intern Med. 2020;35(12):3644–49. https://doi.org/10.1007/s11606-020-06235-w . Ricotta DN, Hale AJ, Freed JA, Taylor JL, Smith CC. Peer observation to develop resident teaching. Clin Teach. 2020;17(5):521–25. https://doi.org/10.1111/tct.13134 . McKeon BA, Ricciotti HA, Sandora TJ, Ramani S, Pels R, Miloslavsky EM, et al. A consensus guideline to support resident-as-teacher programs and enhance the culture of teaching and learning. J Grad Med Educ. 2019;11(3):313–18. https://doi.org/10.4300/JGME-D-18-00612.1 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-4888330","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":352399358,"identity":"e5330ef7-1265-4d85-8e93-ede5062227ba","order_by":0,"name":"Min Xu","email":"","orcid":"","institution":"1 Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan 430071","correspondingAuthor":false,"prefix":"","firstName":"Min","middleName":"","lastName":"Xu","suffix":""},{"id":352399359,"identity":"2cce0d89-9e2e-4ecd-a089-b6bba4925d16","order_by":1,"name":"Hongmei Shi","email":"","orcid":"","institution":"1 Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan 430071","correspondingAuthor":false,"prefix":"","firstName":"Hongmei","middleName":"","lastName":"Shi","suffix":""},{"id":352399360,"identity":"0f25c16a-8526-434f-831f-b0871388f639","order_by":2,"name":"Youren Zhang","email":"","orcid":"","institution":"2 School of Public Health, Wuhan University, Wuhan 430071","correspondingAuthor":false,"prefix":"","firstName":"Youren","middleName":"","lastName":"Zhang","suffix":""},{"id":352399361,"identity":"52438291-01e6-40b6-b14c-ce87f0c0c30a","order_by":3,"name":"Hong Lei","email":"","orcid":"","institution":"3 Teaching Affair Office, Zhongnan Hospital of Wuhan University, Wuhan 430071","correspondingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Lei","suffix":""},{"id":352399365,"identity":"70809bc6-cc55-42f3-99eb-1059607afcc7","order_by":4,"name":"Miao Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBAC9nYEm/FBQkUNYS08hxFsZoMHZ46RpoVN8mELMxFamJmPffi4w06OQSI7rSKxgY2Bv707gYAWtuSZM88kGzNI5G67kbhDhkHizNkNeLXYM/MYM/O2HUhsAGs5w8ZgIJGLXwsPSMvftgP1IC0FiW3MRGphbDuQAHIYA5Fa2JIZe9uSDRt43m6WSDhzjIegX3jYmw8z/Gyzk2dgz9348UdFjRx/ey9+LXBgfyEBYgZxysGA/wAJikfBKBgFo2BEAQAq70GA7sy4zgAAAABJRU5ErkJggg==","orcid":"","institution":"3 Teaching Affair Office, Zhongnan Hospital of Wuhan University, Wuhan 430071","correspondingAuthor":true,"prefix":"","firstName":"Miao","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-08-09 16:29:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4888330/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4888330/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":64615669,"identity":"3cb3e3f3-a734-4c9a-9c1a-37e7a97a2ffa","added_by":"auto","created_at":"2024-09-16 15:07:43","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":360576,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4888330/v1/8184924ece2377a1f889b16d.jpg"},{"id":64615671,"identity":"ed82ddf7-c3ab-485d-a5f8-22abd57bde4e","added_by":"auto","created_at":"2024-09-16 15:07:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":364938,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4888330/v1/0f0cecfc94742a0a62a10513.jpg"},{"id":64615670,"identity":"1fb4bfbb-1f75-4c13-9744-128fe662657f","added_by":"auto","created_at":"2024-09-16 15:07:43","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":342911,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4888330/v1/2859445788a2a82052455977.jpg"},{"id":83443205,"identity":"44e41b49-e5b4-4516-a1a5-6b617de85747","added_by":"auto","created_at":"2025-05-26 10:17:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1788042,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4888330/v1/1aeda83d-353e-4322-9f10-ec329856353e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Deliberate Practice: A Framework for boosting pre-clerkship clinical skills","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eClinical skills performance is a core competence for medical students. In traditional medical educational program, clinical skills performance training is mainly implemented during the clinical clerkship, while the theoretical and apprenticeship learning of medicine were mainly carried out in pre-clinical period for students[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Increasing evidence and experience from medical educators indicated that pre-clerkship students confronted difficulties and often felt unprepared when transiting from didactic learning to clinical rotations[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In real-world clinical settings, students have been expected to take medical histories, examine patients, or perform certain essential procedural tasks, while patients desire safe and harm-free expert care. Competence-based clinical skills performance training is required to ensure enough clinical practice for first-year clerkship students as well as the safety of individual patients[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDeliberate practice has been proved for its effectiveness in clinical skills training [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Taking Skills Boot Camp as example, it has been demonstrated that enhanced skills training contributes to help residents to attain clinical competence when performing on patients[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, there is a lack of comprehensive clinical skills training curriculum in pre-clerkship period. Therefore, we instituted a two-week competence-oriented enhanced clinical skills performance training curriculum under the frameworks of deliberate practice. This study is aimed at exploring effective teaching frameworks and modalities to deliver high-quality clinical skills performance training for pre-clerkship students, which also provide evidence for decision-making of medical education policy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants and settings\u003c/h2\u003e \u003cp\u003eA total of 157 medical undergraduates graded in the 4th academic year from the 2nd affiliated clinical college of Wuhan University, China were enrolled in this study. The enrolled students previously received medical education under the same teaching syllabus and requirements. Instructors with medical faculty qualification formed the responsible teaching staff of the enhanced clinical skills performance training curriculum. Each enhanced performance training session was undertaken by the same instructor during the curriculum. An instructor/student ration of no more than 1:10 was required to assure proper assistance and supervision in the performance training scenarios.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eDesign of the enhanced clinical skills performance training curriculum\u003c/h2\u003e \u003cp\u003eThe enhanced clinical skills performance training curriculum focused on medical history-taking, physical examination, and essential procedural skills. Twenty-five simulated performance training sessions were imparted for undergraduates at the start of their clinical clerkship. Before the start of each performance training session, online delivery of review materials for each clinical skill was provided to students. These materials included didactic materials, audio/visual resources, and various reference materials such as electronic textbooks, procedural manuals, and reputable internet websites. The enhanced clinical skills performance training employed a simulation-based pedagogical approach within simulated clinical scenarios, adhering to a structured six-step LSPPDM teaching process as follows: learn, see, practice, prove, do, and maintain[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. All students were required to undergo pre- and post-training competence assessment through an Objective Structured Clinical Examination (OSCE)[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The following provides a detailed description of the concrete implementation of enhanced clinical skills performance training in medical history-taking, physical examination, and essential procedural skills.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e\u0026#150; Procedures of enhanced medical history-taking training\u003c/h2\u003e \u003cp\u003eEnhanced clinical skills performance training of medical history-taking was implemented utilizing a self-developed Standard Patients (SPs) virtual medical video-interview system. SPs were recruited and trained by the Standard Patients Training Association of the 2nd affiliated clinical college, Wuhan University. SPs with training qualifications will be included in the virtual medical video-interview system. A symptom-oriented case library with scoring criteria for evaluating medical history-taking skills, was developed to synchronize with the SPs virtual medical video-interview system. Students conducted medical video-interviews with SPs using cases which randomly assigned. The instructor scored students\u0026rsquo; video-recorded medical history-taking performances according to the scoring criteria accessible through educator\u0026rsquo;s portal of the Standard Patients (SPs) virtual medical video-interview system, and provided specific feedback to help students identify their strengths and areas for improvement.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e\u0026#150; Procedures of enhanced physical examination training\u003c/h2\u003e \u003cp\u003eFour simulated clinical scenarios were designed for physical examination training sessions, each corresponding to the examinations of the thoracic, cardiac, abdominal, and neurological systems.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e\u0026#150; Procedures of essential procedural skills training\u003c/h2\u003e \u003cp\u003eEssential procedural skills training imparted twenty simulated training sessions, each focusing on a different essential procedural skill. The involved essential procedural skills included the following items: thoracentesis, abdominocentesis, lumbar puncture, bone marrow puncture, Sengstaken-Blakemore tube placement, nasogastric intubation, urethral catheterization, adult cardiopulmonary resuscitation, defibrillation and synchronized cardioversion, artery puncture and blood gas analysis, venous puncture and transfusion, and fundamental surgical skills which included surgical scrubbing, gowning and gloving, surgical area disinfection and clothing, incision and drainage, sutures and ligaturing, hemostasis, dressing change and suture removal. Additionally, first-aid skills for trauma including wound debridement and bandaging, handling of suspected spinal injuries, fixation of extremities fracture, sputum suction and choking-Heimlich maneuver, oxygen therapy. Finally, donning and doffing personal protective equipment, such as isolation gown and protective suits, were also included in the procedural skills training curriculum.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOutcome measures\u003c/h2\u003e \u003cp\u003eIn the OSCE\u0026rsquo;s assessment, all students were required to randomly select the medical history-taking, physical examination, and the procedural task they had to perform as they progressed through the examination. Clinical skills performance scores in medical history-taking, physical examination and a procedural skill were analyzed from the pre- (OSCE-2) and post-training OSCE assessments (OSCE-3). Furthermore, The OSCE final examination scores from the diagnostic skills curriculum (OSCE-1), administered to the same cohort of students two years ago, were also referred in the analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eData was analyzed using R version 4.4.1. Continuous variables in the study were expressed as median (with interquartile ranges, IQRs) due to a non-normal distribution of data. The Friedman test was applied to perform comparisons for the medians of students\u0026rsquo; performance in medical history-taking, physical examination, and a procedural skill across the three OSCE examinations. Nemenyi post hoc comparisons were used to assess differences among parameters of medical history-taking, physical examination, and a procedural skill across the three OSCE examinations. Statistical significance was defined as a two-tailed p-value of less than 0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e1. Pre-clerkship students\u0026rsquo; skills performance in medical history-taking\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, pre-clerkship students\u0026rsquo; skills performance in medical history-taking during the pre-training OSCE assessment (OSCE-2) showed no significant difference compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1) [79.50(9.50) in OSCE-1 vs 79.50(9.50) in OSCE-2, q\u0026thinsp;=\u0026thinsp;1.767, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.424]. However, significant improvement of skills performance in medical history-taking was observed during the post-training OSCE assessment (OSCE-3), compared to their medical history-taking skills performance in OSCE-2 [83.50 (7.25) in OSCE-3 vs 79.50 (9.50) in OSCE-2, q\u0026thinsp;=\u0026thinsp;7.028, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the data distribution revealed that there were more high-scoring students in the post-training OSCE assessment (OSCE-3).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2. Pre-clerkship students\u0026rsquo; skills performance in physical examination, and essential procedural skills\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, pre-clerkship students\u0026rsquo; skills performance in physical examination and essential procedural skills declined significantly during the pre-training OSCE assessment (OSCE-2), compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1) [95.10 (5.80) in OSCE-1 vs 85.00 (8.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;15.840, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. However, significant improvement of skills performance in physical examination skills was revealed during the post-training OSCE assessment (OSCE-3), compared to their skills performance in pre-training OSCE assessment (OSCE-2) [90.25 (7.38) in OSCE-3 vs 85.00 (8.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;7.430, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. Similar significant improvement of essential procedural skills performance was observed between the pre-training OSCE assessment (OSCE-2) and the post-training OSCE assessment (OSCE-3) [95.00 (4.63) in OSCE-3 vs 88.00 (14.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;9.247, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]. As illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the data distribution revealed that there were fewer students in the lower score brackets after completing the enhanced clinical skills performance training curriculum.\u003c/p\u003e \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\u003ePre-clerkship students\u0026rsquo; clinical skills performance in OSCE assessments\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\u003eclinical skills\u003c/p\u003e \u003cp\u003eperformance\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003emedian (IQR)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eFriedman test\u003c/p\u003e \u003cp\u003eχ\u0026sup2;\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ePairwise Comparison\u003c/p\u003e \u003cp\u003eNemenyi test q value, and \u003cem\u003ep*\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOSCE-1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOSCE-2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOSCE-3\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emedical\u003c/p\u003e \u003cp\u003ehistory-taking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.50(9.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e27.802\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.767,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep*\u003c/em\u003e=0.424\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.261,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.50(9.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.028,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep*\u003c/em\u003e\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.50(7.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ephysical examination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.10(5.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e126.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e15.840,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e8.410,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.00(8.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7.430,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.25(7.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eessential procedural skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.00(10.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e44.995\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.284,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3.963,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*=0.014\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88.00(14.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.247,\u003c/p\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e*\u0026lt;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOSCE-3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.00(4.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote:\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eNA\u0026thinsp;=\u0026thinsp;not applicable.\u003c/p\u003e \u003cp\u003e \u003cem\u003ep\u003c/em\u003e values were calculated with the Friedman test.\u003c/p\u003e \u003cp\u003e \u003cem\u003ep\u003c/em\u003e* values were assessed with the post hoc Nemenyi test.\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, competence-oriented enhanced clinical skills training curriculum was designed to investigate its effectiveness on clinical skills competence in pre-clerkship students. We found that clinical skills performance of pre-clerkship students tended to decay with time, but then rebounded after the refresher training. These findings demonstrated that a structured program of deliberate practice in clinical skills contributed to improve clinical skills competence of pre-clerkship students.\u003c/p\u003e \u003cp\u003eMedical history-taking and physical examination skills are essential components of clinical competence in medical education, which requiring a systematic and patient-centered approach. However, it has been repeatedly reported that medical students or first-year residents showed a lack of confidence and with little preparation or formal instruction when suddenly were asked to take medical history and examine patients in real-world clerkship [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In our study, physical examination skills of pre-clerkship students decayed significantly in the pre-training OSCE assessment (OSCE-2), compared to the OSCE final examination scores from the diagnostic skills curriculum which administered to the same cohort of students two years ago (OSCE-1). Both medical history-taking and physical examination skills performance showed significant improvement after the refresher training. These findings are line with the educational philosophy of deliberate practice. Clinical skills with limited opportunity for practice present natural skill degradation without refresher training[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Deliberate practice is characterized of highly structured training activity oriented to improve specific technical skills. It has been confirmed for effective skills training, underling repetitive practice and formative feedback [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, our curriculum team made several targeted methodological improvements in the enhanced skills performance training of medical history-taking and physical examination. First, the implementation of self-developed Standard Patients (SPs) virtual medical video-interview system offered more opportunities of deliberate practice with videorecording feedback for students. This innovative training approach has addressed the specific limitations in medical history-taking instruction, including a shortage of educational manpower, stringent time constraints, budgetary restrictions, and limited resources[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The remarkable improvement of medical history-taking skills performance was also attributed to the establishment of a structured educational framework, with standardized qualification of SPs behaviorism, symptom-oriented case library and standardized scoring criteria for medical interviews feedback[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. All these refinements ensure the standardization and homogeneity of the training in medical history-taking. Second, in our enhanced physical examination skills performance training, a \u0026ldquo;core\u0026thinsp;+\u0026thinsp;clusters\u0026rdquo; strategy was applied, integrating symptom-driven clusters of additional medical histories into the core curriculum[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Students conducted repetitive practice on simulated human models incorporating clinical reasoning in four different clinical scenarios, including cardiovascular, breast, abdominal, neurological, and spinal physical exam maneuvers. The educational framework of deliberate practice was instrumental in the significant improvement in physical examination skills performance, with clinical reasoning and critical thinking being another key contributor [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe present study also observed similar essential procedural skills decay with time followed by significant improvement of procedural skills performance after the enhanced training. This finding again confirmed the effectiveness of deliberate practice in medical procedural skills training, which contributing to consolidate learning and improve procedural skill performance through constructive practice repetition and formative feedback[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, the LSPPDM teaching model also played an important role in the significant improvement of essential procedural skills performance[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The pedagogical frame of \u0026ldquo;learn, see, practice, prove, do, maintain\u0026rdquo; (LSPPDM) emphasizes the importance of a structured but step-by-step approach to learning and maintaining procedural skills in medicine[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Our data demonstrated its effectiveness in training pre-clerkship students to perform procedural procedures competently. In terms of the comprehensive feedback for procedural skills performance, both teacher feedback and students\u0026rsquo; peer feedback were adopted in the simulated skills performance training process. Previous studies have showed that peer feedback contributed to improve learning outcomes and confidence[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. During the process of deliberate practice, it is important to involve observing students to remain attentive and learn from each other. The strategy of offering peer feedback from observing students facilitated greater students\u0026rsquo; engagement and motivation during the enhanced training of essential procedural skills[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, this observed influence of observing students\u0026rsquo; peer feedback is proposed from the authors\u0026rsquo; experience. The impact of peer observation and feedback on procedural skills acquisition in the pedagogical frame of this study needs further investigation.\u003c/p\u003e \u003cp\u003eThere are several limitations of this study. First, due to the limited time in the practice session of each training item, we did not conduct a cross-design to ensure equal deliberate practice frequency of each participant. Second, confined to the educational schema of clinical medicine, the time intervals of clinical skills performance in three OSCE assessments were not the same, we could not distinguish the short-term refresher training effects from long-term retention. Given the above limitations, studies exploring the impact of deliberate practice refresher frequency and to identify the optimal timing for preventing clinical skills decay after the enhanced training need to be further investigated. Nevertheless, we remain committed to refining the curriculum design of clinical skills performance enhancement program.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe enhanced clinical skills performance training under the framework of deliberate practice in pre-clerkship students contributed to the improvement of clinical skills performance. Strategies facilitating the transition from preclinical to clinical training are crucial for ensuring clinical skills competence in pre-clerkship students. Effective teaching modalities and advanced methodologies of the present study served as references to peers for best practices in evidence-based medicine education.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by ethics committee of Zhongnan Hospital, Wuhan University, and informed consent was obtained from all enrolled participants.The ethical approval number is No.2023030k.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have approved the manuscript for publication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData are incorporated into the article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1 Department of Geriatrics, Zhongnan Hospital of Wuhan University, Wuhan 430071, China\u003c/p\u003e\n\u003cp\u003e2 School of Public Health, Wuhan University, Wuhan 430071, China\u003c/p\u003e\n\u003cp\u003e3 Teaching Affair Office, Zhongnan Hospital of Wuhan University, Wuhan 430071, China\u003c/p\u003e\n\u003cp\u003eCorrespondence: Miao Yang; email: [email protected]\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e Wuhan University\u0026rsquo;s Residency Training Teaching Research Project, Innovative mobile App-based heart auscultation skills training platform development (2024011); Hubei Province Higher Education Association Project, Development and application of an online medical history-taking platform in the era of new medical science (2023XC072); Ministry of Education Industry-Academia-Research Project, Future professional competency enhancement for medical students (230901449064603); Wuhan University\u0026rsquo;s Undergraduate Education Quality Comprehensive Reform Project, Pioneering career competence-based skill assessment models for medical interns (2024-32-10).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMin Xu managed the curriculum\u0026rsquo;s execution and ensured its quality, undertook data collection, and wrote the original draft. Hongmei Shi was engaged in the implementation of the curriculum. Youren Zhang was responsible for data statistical analysis. Hong Lei was engaged in the curriculum\u0026rsquo;s implementation and provided supervision. Miao Yang was responsible for the curriculum\u0026rsquo;s implementation and administrative tasks. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThanks to the dedicated teaching staff and engaged students of the 2nd affiliated clinical college of Wuhan University, China. Appreciation is extended for the contributions made in the organization, implementation, and management of this enhanced clinical skills performance training curriculum.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLofaso DP, DeBlieux PM, DiCarlo RP, Hilton C, Yang T, Chauvin SW. 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J Grad Med Educ. 2019;11(3):313\u0026ndash;18. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4300/JGME-D-18-00612.1\u003c/span\u003e\u003cspan address=\"10.4300/JGME-D-18-00612.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"clinical skills, medical history-taking, physical examination, procedural skills, pre-clerkship, clinical competence, deliberate practice","lastPublishedDoi":"10.21203/rs.3.rs-4888330/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4888330/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eClinical skills performance is a core competence for medical students, yet many pre-clerkship students encounter significant challenges in applying clinical skills effectively during their transition to clinical rotations. This study aims to explore effective training frameworks and pedagogical approaches that enhance clinical skills performance, thereby facilitating the transition from preclinical to clinical clerkship and fostering the development of clinical competence.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 157 pre-clerkship students graded in the 4th year were enrolled in this study. All the students underwent two-week enhanced performance training in clinical skills which focusing on medical history-taking, physical examination, and essential procedural skills. Two competence-based evaluations in the form of objective structured clinical examination (OSCE) were implemented before (OSCE-2) and after (OSCE-3) the enhanced performance training for the students. Additionally, OSCE scores of clinical diagnostic curricula (OSCE-1) which conducted two years ago were referred for comparison.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe medical history-taking performance of pre-clerkship students demonstrated fine skills retention in the pre-training OSCE examination [79.50 (9.50) in OSCE-1 vs 79.50 (9.50) in OSCE-2, q\u0026thinsp;=\u0026thinsp;1.767, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.424]. However, both performance of physical examination [95.10 (5.80) in OSCE-1 vs 85.00 (8.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;15.840, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001]and essential procedural skills [93.00 (10.00) in OSCE-1 vs 88.00 (14.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;5.284, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] showed a significant decay with time. Skills performance in medical history-taking [83.50 (7.25) in OSCE-3 vs 79.50 (9.50) in OSCE-2, q\u0026thinsp;=\u0026thinsp;7.028, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], physical examination [90.25 (7.38) in OSCE-3 vs 85.00 (8.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;7.430, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001], and essential procedural skills [95.00 (4.63) in OSCE-3 vs 88.00 (14.00) in OSCE-2, q\u0026thinsp;=\u0026thinsp;9.247, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001] all showed significant improvement after the enhanced skills performance training.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe enhanced clinical skills performance training curriculum contributed to facilitate the transition from preclinical to clinical clerkship with improving skills performance. The aligned framework of deliberate practice and advanced teaching modalities showed significant effectiveness in the enhanced clinical skills performance training for pre-clerkship students, which providing reference to peers for best practices in evidence-based medicine education.\u003c/p\u003e","manuscriptTitle":"Deliberate Practice: A Framework for boosting pre-clerkship clinical skills","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-16 15:07:38","doi":"10.21203/rs.3.rs-4888330/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fa684bb7-acde-4a51-9c09-c49a062a28db","owner":[],"postedDate":"September 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-05-26T10:09:00+00:00","versionOfRecord":[],"versionCreatedAt":"2024-09-16 15:07:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4888330","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4888330","identity":"rs-4888330","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}