Evaluating preclinical medical students’ self-perceived OSCE performance: Content versus interpersonal skills

Evaluating preclinical medical students’ self-perceived OSCE performance: Content versus interpersonal 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 Evaluating preclinical medical students’ self-perceived OSCE performance: Content versus interpersonal skills Julie Rebecca Wechsler, Stacey Rose This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8512849/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Effective communication is a key skill for medical trainees (Correa et al. 2025). This requires both knowledge and interpersonal skills. The former is obviously a major component of medical school curricula, but the latter is also increasingly taught intentionally (Flanagan & Cummings 2023; Gilligan et al. 2021). Objective Structured Clinical Examinations (OSCEs), which give students experiential practice and individualized feedback, are frequently used to this end (Brogan et al. 2016; Cvengros et al. 2016; Reid et al. 2016; Sedler et al. 2025; Talwalkar et al. 2021). At our institution, an OSCE is completed at the end of the preclinical phase of medical school, which is a fascinating inflection point in the curriculum; students have been learning clinical reasoning and interpersonal skills through their coursework, but they have yet to apply them to real patient encounters. In this study, we analyze written reflections composed after this OSCE to interrogate the balance between these two skillsets: to what extent do preclinical medical students turn their focus to the content of the interaction (medical knowledge) versus the delivery (interpersonal skills)? Methods Second-year medical students completed an OSCE exercise and written reflection. The resulting 288 reflections were analyzed using a thematic analysis framework. Codes were identified based on common competencies assessed in learners and categorized as either “interpersonal”- or “content”-related. Results Analysis revealed that students see room for improvement with both interpersonal skills and content areas, highlighting behaviors that are important but not yet mastered. There was greater focus on interpersonal than content, but many students described how the two intertwine in a medical encounter. Major themes included the idea of balance and looking to the future, as well as the importance of reflection in professional identity formation. Conclusions Preclinical medical students are able to reflect on the balance between interpersonal skills and medical content. Detailing their current practices informs where they may need greater instruction. Ultimately, this work aims to contribute to a more detailed understanding of how we can prepare students to be strong communicators as they transition to the clinical environment. preclinical medical students OSCE reflection interpersonal skills medical knowledge Figures Figure 1 Background Effective communication in medicine has been shown to improve patient-related experiences like satisfaction, trust, and understanding, which are in turn associated with better health outcomes ( 1 – 3 ). Given the importance of good communication, the Accreditation Council for Graduate Medical Education (ACGME) prioritizes interpersonal and communication skills as a core competency for training physicians ( 4 ). A large body of research exists on training this competency, evaluating both in-person and virtual formats, and ranging from individual work with standardized patients to larger-group work ( 5 , 6 ). Such training courses are generally found to have some positive effect on students’ overall communication skills, empathy, and information gathering ability ( 6 ). Simulation, as with the Objective Structured Clinical Examination (OSCE) format, is a frequently employed method, as it gives students experiential practice and individualized feedback ( 7 – 11 ). Clinical rotations are a rich opportunity for honing of communication and clinical reasoning skills ( 12 ). As a result, skills interventions are often conducted with clinical-level students, leaving students in the preclinical time somewhat underrepresented ( 13 , 14 ). Yet the end of the preclinical phase of the curriculum is a fascinating inflection point, particularly with respect to clinical reasoning and interpersonal skills, two skills OSCEs are often designed to assess ( 15 – 17 ). At our institution, an OSCE is completed at this moment before the transition to clinical clerkships. Afterward, students are asked to evaluate their performance via a self-rated interpersonal skills score and written reflection. On the one hand, students have just completed the basic science curriculum, which leans heavily toward building a base for clinical reasoning and would suggest that their focus at this time is on medical knowledge. On the other hand, as they wrap up their Doctoring and history-taking courses and mentally prepare to start on the wards, they may instead be pondering how to apply interpersonal skills to real patient interactions. In this study, we interrogate the balance between these two broad skillsets: in reflecting on an OSCE exercise, how do preclinical medical students perceive their performance in terms of the content of the interaction (medical knowledge) versus the delivery (interpersonal skills)? In asking these questions, it’s important to define these two categories carefully. Definitions for interpersonal skills vary, but most comprise both verbal and nonverbal behaviors ( 18 , 19 ). Verbal behaviors include what students actually say; for instance, using suitable language, open-ended questions, empathic words, and summary statements ( 19 – 21 ). Verbal behaviors help accomplish the provider’s objectives, but they can also influence the patient’s perception of the visit ( 20 , 22 , 23 ). Nonverbal behaviors also influence patients’ experiences of the encounter ( 24 , 25 ). Nonverbal behaviors are paralinguistic practices such as body orientation and body language ( 26 , 27 , 19 , 24 ); gaze and eye contact ( 19 , 24 , 28 ); facial expressions ( 26 , 29 ); voice characteristics such as tone, speed, and volume ( 24 , 26 – 28 ); touch ( 29 ); and so-called unpurposive movements, such as touching one’s face or interacting with a pen or other object in the vicinity ( 20 , 29 ). These play an important role in conveying empathy and emotion in all encounters, whether primarily medical-focused or psychosocial ( 21 , 26 ). Verbal and nonverbal behaviors can be assessed externally by observer ratings ( 20 , 28 ), or, less commonly, by students’ qualitative self-perceptions ( 19 , 30 ). In contrast, the medical knowledge component is more often measured by formal assessments like case activities, written examinations, or oral examinations ( 31 , 32 ). Increasingly, educators may attempt to link basic science concepts to clinical scenarios ( 31 ). Nevertheless, an OSCE may be one of the first times where medical knowledge is experienced as a key part of the patient encounter, rather than a distinct entity. Reflecting on an OSCE therefore brings the two components, interpersonal (verbal and nonverbal) and medical knowledge, together. At this level, even if the primary goal of the OSCE might be to work on interpersonal skills, the medical knowledge is particularly salient, as these students are still learning the content. The goal of this study is to explore how students view the balance between these skills, and what they perceive to be their own strengths and areas of improvement in both regards. It is important for physicians to be able to assess their own performance once they are in practice, so it is also critical for students to begin to understand their own communication practices early on in training ( 33 , 34 ). The act of reflection is crucial not only for improving communication behaviors ( 35 ), but more broadly for forming a professional identity ( 36 , 37 ). At this point, students’ own insights are a valuable glimpse into the minds of those who are just beginning to identify themselves as part of the medical profession. Reviewing self-assessments of preclinical students both details current communication practices and points to where students may need greater instruction at this level of training. Ultimately, this work aims to contribute to a more detailed understanding of how we can prepare students to be strong communicators as they transition to the clinical environment. Methods The OSCE format is employed throughout our institution’s curriculum, most notably at the end of each clerkship block (internal medicine, pediatrics, family medicine, surgery, emergency medicine, neurology, psychiatry, obstetrics/gynecology). At the end of the 18-month pre-clinical curriculum, second-year medical students participate in the Core 1 OSCE, which is their first exposure to the OSCE format and simulation center procedures. Afterward, they respond in writing to a prompt about their communication skills, and the resulting reflections were the data source for this work. We examined reflections of all students who took the Core 1 OSCE in the years 2023 and 2024. The prompt asked students to rate their interpersonal skills based on a provided checklist, then suggest strategies for improvement, without specifying whether they should answer with a content item or an interpersonal skill (see Appendix). This study was reviewed by the University of Pennsylvania IRB and given an exempt determination (protocol #859227). Per the Common Rule CFR 46.104, Category 4 ( 38 ), no consent was required given that the reflections were secondary data and completely deidentified. We conducted a mixed-methods study using a constructivist approach, acknowledging that conclusions are socially constructed, in contrast to the post-positivist view’s search for an objective truth ( 39 ). The data were reviewed using iterative thematic analysis. After an initial review of the reflections, tentative codes were identified and used to approach the codebook more deductively, regrouping the initial codes under the categories “interpersonal” (verbal and nonverbal) and “content.” Within these, we used the AAMC/ACGME core competencies ( 40 ) and the interpersonal skills checklist (see Appendix) to refine the specific behaviors of interest. In the end, the Interpersonal category included Eliciting Information, Listening, Giving Information, Respectfulness, Empathy , and Professionalism ; the Content category included Medical Knowledge, Patient Care , and Systems-Based Practice (see Appendix for full codebook and representative quotations). Consensus coding was carried out to strengthen the themes and ensure intelligibility of the codebook. Approximately 10% of the reflections (30 total) were reviewed by a coder external to the project using the original codebook. Discrepancies were discussed and resolved with the primary researcher (J.R.W.). The updated codebook was then utilized to analyze the rest of the data, 288 reflections in total. This method combined the reflexive and coding reliability approaches which have been described in the literature ( 41 ); though the coding process has an inherent degree of subjectivity, we wanted to ensure that the codebook organization and definitions made sense to someone unaffiliated with the project. After the initial coding of the text, each reflection was labeled as primarily Content or primarily Interpersonal based on their answer to the last question, “What new element would you address if you could repeat the encounter?”. If students did not explicitly say “If I could repeat the encounter, I would...”, this label was based on the overall paragraph. Results and Discussion Several major themes emerged from the student reflections of their Core 1 OSCE performance: 1. Interpersonal skills, 2. Content, 3. Finding balance, 4. Future. Of the 288 reflections analyzed, 193 (67%) focused on only interpersonal items, 38/288 (13%) focused only on content items, 55/288 (19%) talked about both interpersonal and content, and 2/288 (0.7%) did not state a future element to address. Sample quotations are provided, with the number of the student reflection provided in parentheses. Interpersonal skills The majority of students focused on their interpersonal skills during the encounter. Subthemes of verbal and nonverbal skills emerged for most of the interpersonal skills checklist categories, though students more frequently talked about verbal skills than nonverbal (or paraverbal) skills, as shown in Fig. 1 . Students who focused on interpersonal skills most frequently addressed the subthemes of Eliciting Information , followed by Giving Information – Verbal and Professionalism , as shown in Table 1 . Table 1 Frequency of mention of each Interpersonal category (total number of students who focused on Interpersonal : 193; total number of mentions of an Interpersonal theme: 303). Interpersonal only Number of mentions (out of 303) % Eliciting Information 68 22.4 Giving Information – Verbal 44 14.5 Professionalism 40 13.2 Listening – Verbal 31 10.2 Professionalism – Verbal 29 9.6 Respect/Empathy – Verbal 25 8.3 Listening – Nonverbal 22 7.3 Professionalism – Nonverbal 22 7.3 Respect/Empathy – Nonverbal 11 3.6 Giving Information – Paraverbal 11 3.6 The Eliciting Information category covered how students asked questions (open- versus close-ended, understandable versus unclear, stacking questions) as well as some example questions, such as assessing patient understanding and asking if the patients had any questions. For the Giving Information – Verbal category, students reflected on how well they explained information to their patients. This presented an interesting conundrum—when students are still learning the material themselves, it can be a challenge to teach it appropriately, as one student described: “I struggle to allow myself to offer information to my SPs out of fear that my information (diagnoses, medication side effects, etc.) may be wrong or incomplete. As I continue to progress in my understanding, I need to remind myself to feel more confident sharing what I do know and being more comfortable explicitly acknowledging my limitations and letting them know I will be sure to ask more senior members of the care team for answers to those questions.” (#189) In the same vein, many students mentioned a desire to share their reasoning with patients. This is consistent with the trend that medicine is shifting away from the paternalistic view it has been characterized by in the past; rather than telling patients what to do, doctors increasingly explain their thought processes and rationale for diagnostics and treatment ( 42 ). In sharing information, though, students mentioned some occasions where they could have been clearer or provided more detail. They also occasionally overwhelmed the patient with information or came across as patronizing, which is perceived negatively by patients ( 23 ). Many discussed their use of medical terminology, and how that landed with patients: “It felt tricky to summarize the medical jargon in a way that is easy to understand.” (#23) “I think by using his medical diagnosis I confused him, and I may have made him feel incompetent for being confused. Thus, next time I will make sure to frame my questions more open-ended, with less medical jargon.” (#34) “I also want to practice more explaining complicated processes like heart failure in lay terms so that I feel more at ease communicating these things to patients.” (#61) Accumulating medical terms is an inherent part of medical training, but using unfamiliar terms—something providers are not always aware of doing—might confuse the patient ( 43 ). On reflection, students learned to pay attention to their word choice. The counterpart of the Giving Information – Verbal category was Giving Information – Paraverbal , which refers to voice characteristics (pace, tone, volume, articulation, mumbling) and filler words such as “um” and “uh.” It has been widely acknowledged that communication skills trainings should include nonverbal skills ( 20 , 21 , 26 , 27 , 29 ). Interestingly, this was the least-cited area for improvement, and the other Nonverbal subcategories were not brought up as often either. Though the lower numbers in our sample suggest that this area is a minor issue for most students, it did appear to be helpful for some students to recognize their verbal tics. Professionalism was the third-most common area for improvement, along with its verbal and nonverbal sub-categories. For the Verbal subcategory, students noted the importance of appropriate introductions, professional word choice, and logical progression of the visit. Many talked about using signposting phrases so patients understand what is coming next, as well as outlining a roadmap in their own minds to keep themselves on track. For the Nonverbal subcategory, students recognized how distracting behaviors can detract from the visit (e.g., facial expressions, fidgeting, playing with a pen), and how being rushed or flustered can negatively affect the patient’s experience. Relating these behaviors and their outcomes back to one's intent shows a growing self-awareness ( 44 ): “My biggest point to fix is in being able to not let my own frustration with my questioning show up in my face. While it is understandable that we are still working on our history-taking, I need to remind myself that how I am delivering questions and receiving answers really matters in making the patient feel comfortable.” (#269) Understanding how one’s own behaviors influence another person’s experience of the interaction (positively or negatively) is key for productive communication ( 35 ). Students described the difficulty of staying engaged with the patient when dealing with the cognitive load of the situation. Whether it was that the OSCE format felt unfamiliar; thinking of what to ask next; or balancing asking questions, note-taking, appropriate eye contact and body language, students recognize that the multitasking involved in history-taking should not distract from being present with the patient: “Sometimes when my mind is distracted thinking about what to ask next, I can miss what my SP is telling me. This ends up affecting the connection that I could build with them and so it impacts our interaction.” (#72) “In general, when I can just listen and don’t have to think about where I’m going to take the interview next, it’s easier for me to be fully present in the encounter. So I think having a better plan for the flow would make it easier for me to listen effectively. Of course, leaving room to deviate from the plan if needed.” (#83) “I was at time not engaged fully in the conversation because I was taking notes on what the patient was saying. This led to moments where the patient might have felt distant or unheard.” (#231) One of the most common concerns, however, fell under the umbrella category of Professionalism , as it is neither fully verbal nor nonverbal: time management. Other students have also reported struggling with this ( 45 ). Here, they recognize that the time crunch they felt will be an all-too-common occurrence in their future careers: “In clerkships and in the future I will have to become efficient taking histories and doing physical exams so it will be key to come in with a clear framework in my mind of what I want to do.” (#72) “Given that the OSCE was much more concise [than our] previous [Introduction to Clinical Medicine course] sessions, and I suspect the timing on the wards could also be tight, I will... lean more into guiding the conversation to inquire about necessary topics... while at the same time give space for the patient to tell their story.” (#147) Relatedly, students cited organization and structuring of the interaction as two other areas of improvement, which have also been described previously ( 44 , 45 ). To deal with this, they emphasized the need to be prepared before the visit and efficient during the interaction. Preparation is a careful balance, though. On one hand, knowing what questions to ask streamlines the interaction and offloads some of the cognitive burden; on the other hand, going too far in that direction might sound overly rehearsed, or make the conversation so inflexible that the conversation is no longer guided by the patient (as one student pointed out). Our findings tie into the debate regarding the extent to which interpersonal skills can be taught ( 46 ). Students come into medical school carrying unique personalities and experiences that influence how they interact with others, but experiential learning, personal reflection, and guidance from mentors also foster interpersonal skill development ( 47 , 48 ). Given that reflection contributes to skill development, prompts need to be designed intentionally and clearly. Our findings show that the wording of the prompt likely encouraged students to contemplate their interpersonal skills. Medical content Though the assignment might have leaned more toward interpersonal skills, medical content was still highly represented. The 38 students who focused on Content mentioned 44 content areas, with Patient Care (18/44) and Medical Knowledge (17/44) being the most common themes, followed by Systems-Based Practice (9/44), as demonstrated in Table 2 . Table 2 Frequency of mention of each Content category (total number of students who focused on Content : 38; total number of mentions of a Content theme: 44). Content only Number of mentions (out of 44) % Patient Care 18 40.9 Medical Knowledge 17 38.6 Systems-Based Practice 9 20.5 Within Patient Care , the majority focused on components of the social history that they had missed (e.g., asking about occupation, alcohol use, financial situation). A few discussed the fact that the instructions for the OSCE differed from what they were used to, so they were not always able to complete the objectives when they were less familiar (e.g., medication reconciliation, results follow-up, writing a note in a particular style). Under Medical Knowledge , the vast majority of students noted that they should have elicited more specific information about patients’ medications, such as dose, timing, frequency, and purpose. Several noted that they neglected to ask about diet, and a few wished they had discussed the patient’s diagnosis more. Though this code is closely related to the interpersonal Eliciting Information , here students only mentioned what they wish they had asked, without discussing how they would have phrased or approached it. For Systems-Based Practice , students spoke about resources and barriers to care. Many expressed a desire to be more familiar with the resources available to patients, as they felt unable to counsel adequately with their limited knowledge. Similar to the focus on instructions mentioned above, their limited familiarity with resources reminds us of how early these students are in their training. Some guidance (e.g., specific objectives for the session) helps focus the conversation, but too much emphasis on what they don’t yet know can instead distract from the interpersonal aspects of the conversation. Overlap between interpersonal skills and content A large proportion of students discussed both Interpersonal skills and Content items, with the most common subthemes shown in Table 3 . Here we dive deeper into how students notice the overlap and grapple with the tensions between these two areas. Table 3 Frequency of mention of each category when both Content and Interpersonal were brought up (total number of students who mentioned both: 55; total number of mentions of either theme: 128). Both Number of mentions (out of 128) % Patient Care 25 19.5 Medical Knowledge 25 19.5 Eliciting Information 17 13.3 Systems-Based Practice 14 10.9 Giving Information – Verbal 12 9.4 Professionalism 12 9.4 Professionalism – Verbal 9 7.0 Respect/Empathy – Nonverbal 5 3.9 Respect/Empathy – Verbal 4 3.1 Listening – Nonverbal 2 1.6 Listening – Verbal 2 1.6 Professionalism – Nonverbal 1 0.8 Some students in this “Both” category listed separate skills to work on, but many tied them together. For example, several students mentioned that they’d like to improve time management so as to have time to dive into specific topics: "If I could do it all over again, I would review the specific points that they want me to hit on, whether it is insurance or medication adherence or others, and try to focus on them during the encounter. I would try to write these down in an organized step-wise manner so that I can make sure to cover all of those goals before I run out of time." (#72) Like the students who only mentioned Professionalism themes, this student emphasizes the interpersonal ideas idea of efficiency and organization ( Professionalism ) by highlighting specific content ( Medical Knowledge ) details like insurance and medications. Social history topics (such as mental, emotional, and psychological state, or patients' support systems) also came up several times, with the intent of getting at the interpersonal dimension. The goal here was to connect with patients or understand them better: "I could ask him what other people could provide support to him in times of need. Asides from managing [his chronic condition], what does he value in his life and what is he passionate about? Understanding my patient’s goals, values, and preferences can help me develop a better longitudinal relationship with them... and allow me to give better counseling advice." (#138) In addition to asking social history questions, there was overlap with information transfer, such as sharing information and asking about patient understanding. When these ideas were referenced nonspecifically, they were coded as Interpersonal (under Giving Information or Eliciting Information , respectively), but several students brought them up in the context of specific Content details, too. Some students wanted to give clearer explanations on certain topics and fleshed out how they might have phrased things better (#76, 134). Others wanted to explore patients’ understanding by describing their particular medical conditions, rather than stating so generally (#59, 83, 88). In each of these examples, students gave an interpersonal reason for mentioning a content area. This suggests recognition of both concepts as integral to the interaction, reflecting true engagement with the reflection exercise. Balance So far, we have demonstrated that students recognize both the importance of and the intersections between interpersonal skills and medical content. A handful of students mentioned explicitly that there is a balance between interpersonal and content aspects broadly (#150, 245), but several others conveyed the same idea of balance within a single theme. For example, students tried to find the sweet spot between listening and giving information: “I was trying to strike a balance between listening to their story and what barriers to care they might experience while also trying to give helpful and practical advice to try and alleviate some of their problems and worries.” (#4) Within Giving Information itself, there is also a balance, as each patient has a different knowledge base and there is limited time in the encounter: “I wondered if I should give her more information about each drug or be as general as I was. I thought that if I went too in-depth about each drug, she was going to be overwhelmed and was going to get lost. I want to continue developing the right balance between broad explanations and educating my patients well.” (#29) “I was trying hard to find a balance of providing information without being condescending.” (#121) Patient education can include too much or too little information, but it also carries more or less emotional weight depending on the topic. For conversations about uncertain results or potential diagnoses, there is a compromise between focusing on the good news versus the bad news, making sure the patient is fully informed but also not unnecessarily frightened (#214, 259). There is a fine line, too, between giving patients space and making them uncomfortable. Though several students mentioned that they’d like to elicit patient concerns more often, one noted that it’s possible to go too far: “I think one thing I could do to improve my interpersonal skills would be to trust that the patient has raised all concerns and not ask too many times, which can lead to the patient getting worried.” (#98) Underlying the effort to both give and elicit information appropriately is, once again, the idea of limited time. Students struggled with the tradeoff between empathy and efficiency; they want the patient to feel heard and comfortable sharing, but they also need to complete the encounter’s objectives. As with Giving Information above, students debated how to give patients space to speak while also gathering all the details they sought: “I am still finding the balance between letting the patient say all they need to without feeling rushed, while knowing I only have a certain amount of time to get the answers I need.” (#14) “I would like to find the balance between letting the patient’s concerns guide the conversation in order for there to be a better flow in the conversation, while also making sure I don’t forget to ask about certain things.” (#114) “I found it hard to balance getting all the information I needed, specifically when it came to medication reconciliation which is quite time consuming, while also focusing on the interpersonal aspects of the visit.” (#118) “I still struggle with avoiding stacking questions as I try to find the balance between efficiency of discussion and thoroughness of examination.” (#267) Students talked about balancing open-ended and close-ended questions (#204), as well as eye contact versus note-taking (#22, 93, 146). One gave an interesting example of how overcorrection is part of the learning process: “The first encounter, I asked many open-ended questions to grow my understanding of the SP’s situation, but by welcoming their long responses I ran out of time and did not ask all of the questions I wanted. In the second encounter, I tried to work on that and ended up asking many, quick, yes/no questions that did not allow for as much conversation. I think finding a balance will be important in my future interactions.” (#110) Overcorrection also came up in discussions of emotional engagement: “Earlier in the year I felt like I could easily get too emotional, which caused me in future encounters to shut down so that I wouldn’t run the risk of literally breaking down in front of a patient. I felt like this round of encounters I was able to feel a lot more grounded and levelheaded to show empathy without going too crazy with it.” (#161) This student describes how their emotional involvement has shifted over time. The topic of how empathy changes in medical school is well-explored in the literature ( 49 – 53 ). Relatedly, the mental toll of being a physician has been implicated in the development of burnout ( 54 , 55 ). This student’s example provides a glimpse into how one begins to reckon with these difficult aspects of training. The question of balance raises the debate of which is more foundational, medical information or interpersonal skills. One student suggested that the clinical skills come first, and interpersonal skills layer on top: “One specific strategy that I can use to improve my performance is ensuring I am going through systematically... I think this will allow me to lean into the above interpersonal skills without worrying about missing a key question (because I know that I will hit it through my checklist). As a result, I hope to strike a balance of both strong interpersonal engagement but also thorough clinical practice.” (#150) Early in training, attempting to master the content is a large cognitive demand. It is difficult to put that aside to focus fully on interpersonal skills, especially when content examinations are front and center in the preclinical phase and students may be nervous about performing well in the upcoming clerkship year. One student (#68) demonstrated this very clearly—they described how prior experiences (teaching in high school and college, volunteering in medical school) allowed them to feel more comfortable educating the patient and asking about barriers to care. Knowing what to ask about then opened up the space to focus on the delivery of the information (such as speech pace and being concise). This suggests that knowledge is foundational, and the interpersonal is an additional layer that can only be addressed once the knowledge is in place. On the other hand, at a time when knowledge is still building, one thing students have more experience with and control over is how they present themselves. Students can be there for patients even when they don’t have all the details, suggesting that perhaps the interpersonal skills solidify first before the clinical content should be added in. In reality, as this discussion of balance demonstrates, both explanations have merit. Interpersonal skills and content are intertwined and build on each other over time as students gain more clinical exposure. Looking to the future Many students situated the OSCE in the broader context of their medical training. Some looked ahead to being a clerkship student on the wards (#5, 29, 33, 72, 91, 96, 115, 129, 133, 147, 152, 184, 213), to being a practicing physician (#72, 128, 152, 154, 204, 227, 228, 245), or more generally to “the future” or having more experience (#9, 72, 88, 93, 95, 115, 133, 195, 256). They mentioned which skills are important for student doctors and practicing doctors to hone (e.g. making communication “easy and understandable” (#9)).” More clinical experience brings improved medical knowledge and self-confidence, which both bolster communication ( 53 ). Several others instead called back to the past, realizing that they feel more comfortable now in the clinical setting and with history-taking (#33, 103, 116, 160, 161, 248): "Watching my recording again, I feel very impressed at how much I have grown since my first standardized patient encounter. I definitely see myself being more confident in the way I approach these encounters and, thanks to my growing repertoire of medical knowledge, I also feel more confident in the questions that I am asking." (#248) A few also rightfully pointed out that the clinical environment is still new and they are still learning (#117, 258, 269). Framing their development over a longitudinal career demonstrates the ability to envision themselves as a future physician, which is an essential component of reflection ( 56 ) and professional identity formation ( 57 ). Another overarching theme that students cited as important for the future was an increased awareness of these skills in general and increased insight into how they may be perceived. Several students (24/288) shared instances of their actions coming across differently than intended; sometimes more positively, and sometimes more negatively. “There were times when my affect was very animated in an attempt to show that I was actively listening and to demonstrate empathy. However, my SP let me know that this strategy did not always hit the mark. In fact, they mentioned that it can come across as condescending at times.” (#41) “The SP told me that they really appreciated when we stepped back from talking about their medical condition; during the encounter, I was a bit worried that this tangent might take time away from gathering more information/doing a full medicine reconciliation, but contrary to my fear, it gave the patient more comfort overall.” (#64) “I was trying hard to find a balance of providing information without being condescending. I think this could be a really tricky line to balance but the SP told me she didn’t perceive as condescending but helpful.” (#121) “While I normally sit near the patient as a means of establishing rapport, she later told me that this made her feel a little bit nervous. In watching it back, I didn’t feel like I was encroaching on her, however that makes it even more critical to put on my radar.” (#133) In recognizing that their actions may not be perceived as intended, students begin to realize that they must pay close attention to how they speak and carry themselves in the clinical context. They frequently referenced having to be more “cognizant” (#58, 76, 84, 133) of their behaviors, making a “conscious” (#35, 40, 59, 89, 106) or “conscientious” (#96) effort, or “purposely” (#95) adjusting how they interact. Students thus acknowledge their own agency in developing good habits. However, continual external feedback like this exercise is an important component of that process. In reflecting on what elements of a clinical encounter they would change in the future, students mostly focused on interpersonal skills, but many also tied in specific content areas or highlighted content alone. In the following section, we discuss the implications of these findings and the importance of reflection at this stage of medical training. Conclusions The purpose of this study was to examine preclinical medical students’ perceptions of their performance in an OSCE exercise with a specific focus on how they view interpersonal skills versus content. In line with prior research (33), students were able to report on their communication skills and why they are important. Here, the main takeaway was that while preclinical students recognize both categories of skills, their reflections skew toward interpersonal topics more than content. One might have hypothesized that there would be greater emphasis on content, given that students are deep into the basic science curriculum and preparation for clerkships. There are a few possible explanations for why they tend to bring up interpersonal skills more often. First, although the wording of the reflection prompt did not specify what to focus on, they might have been primed to think about interpersonal skills from the first part of the assignment, which was to rate their interpersonal skills based on a rubric. Second, the thought of working with real patients soon—something they have not yet had much practice with—might have attuned students more to the interpersonal aspect of the conversation. But most interestingly, a significant proportion of students talked about both, indicating that even at this early stage of training, they are seeing how the skills overlap and build on each other. In all of the topics raised, another main takeaway is that students at this level are starting to experience the push and pull of communicating as a physician.Preclinical students are learning multiple tasks at once, each of which requires mental energy. According to the cognitive load theory, given the limitations of our working memory, learners (novices in particular) may have difficulty managing simultaneous tasks (58). The theme of balance in our sample, as well as students’ examples of overcorrection, demonstrates that learning is often a matter of trial and error. Perhaps students only addressed one topic at a time because of the cognitive load; this theory reminds us that space must be dedicated to practicing both interpersonal and content areas, rather than a sole focus on one or the other. As students begin to observe patterns, it is crucial for clinician teachers to connect interpersonal skills and content intentionally to help students learn to balance these competing needs (59). That kind of external feedback is important for addressing areas of improvement (33). This was supported by the fact that some topics were raised based on the SP’s feedback. However, most topics came up from students observing their own behavior, highlighting that personal reflection is essential for trainees.Preclinical students have few real-life patient experiences to reflect upon (36); an OSCE simulation, though not a perfect rendering, allows them to practice the crucial skill of self-reflection. Thinking about what is or is not said, how it is said, who is involved, and how each party will react informs communication practices in the future (35). Use of medical jargon is a good example; as these students came to understand, using plain language is particularly important for different levels of health literacy (60), but it is also critical when working with interpreters for languages other than English (61) and just good practice for any patient. This OSCE made students listen to their own words carefully, which informs how they speak with patients moving forward. The reflection exercise was also helpful in that it gave students space to imagine themselves as future providers (62). Our focus on the preclinical phase of the curriculum was intentional because the transition from lecture hall as classroom to the hospital as classroom is an important milestone on the journey of professional identity formation (16). As previously described, our students’ reflections (particularly through writing) helped them situate the exercise in the broader context of medical training and professional identity development (36,37,57,63). Our work underscores the notion that reflection should be introduced early in medical training and remain part of a physician's lifelong professional development (44,64), as the ability improves with practice (56). From the student perspective, viewing their career longitudinally even at this stage reminds us that communication skill building is an iterative process. From the educator’s perspective, we know that effective reflection requires a supportive environment and mentorship (36). As we continuously evaluate medical school curricula, it is imperative to ensure not only opportunities to reflect but faculty support thereof. This study had a few limitations. Given the mandatory nature of the reflection assignment and competing time demands, some students may not have fully engaged in true reflection. The assignment was also based on self-evaluation, and prior work has demonstrated that trainees’ self-ratings do not always correlate with external evaluations (18,34,65–68). Additionally, we must acknowledge that the OSCE format, though useful for maintaining consistency across student interactions, is inherently somewhat artificial (19,69). Real patients assess communication differently than providers and trainees do (69), so it is critical to evaluate communication skills in real-world scenarios, too. There are several avenues of further research that could stem from this work. The reflections assessed in this study were completed after the interaction occurred, which is a commonly used method to develop self-awareness and communication strategies (35). However, this is not the only time point which would be useful; in a future study, students could reflect on communication skills before participating in the OSCE, revealing which skills they are aware of at baseline. It would also be informative to conduct a similar exercise with more advanced students or even residents, since after the preclinical period, formal communication skills curricula decrease while real-world experiences increase (70). Examining how skills change over time would be an interesting example of portfolio learning, the iterative process of collecting experiences, reflection, and feedback and returning to these throughout training (44,71), illustrating whether skill development is more of a conscious evolution or something that comes with experience. Here our focus was on what students need to improve, but it would also be informative to dive deeper into what they felt their strengths were and how their comments correlated with SP comments. Trends may vary based on experiences prior to medical school or anticipated specialty. As medical education explores more personalized curricula, this might help tailor communication trainings to individual students. Part of what makes a good physician, in preclinical medical students’ eyes, is being a good communicator (72). This study’s focus on interpersonal and content skills informs how we design clinical skills education in general. Since content knowledge is necessary for effective communication, we must continue to pinpoint when students have enough content to perform effective interpersonal skills, and relatedly, to what extent we can teach interpersonal skills before that content baseline is achieved. We challenge educators to incorporate reflection early and periodically in pursuit of these goals. In considering the balance of these skills, we hope that early medical students may start building a foundation to be excellent communicators throughout their careers. Abbreviations - OSCE Objective Structured Clinical Examination - SP Standardized Patient Declarations Ethics approval and consent to participate: This study was conducted in accordance with the norms of the Declaration of Helsinki. It was reviewed by the University of Pennsylvania Institutional Review Board, under the University of Pennsylvania Human Research Protections Program. It was deemed exempt (protocol #859227) given that the study design consisted of secondary use of deidentified data. Consent was deemed unnecessary given the completely deidentified nature of the reflections, per the Common Rule (45 CFR 46.104, Category 4). Consent for publication: Reflections were completely deidentified, so consent was not applicable. Availability of data and materials: The qualitative data analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: No funding source exists for this work. Authors' contributions: J.R.W. initially conceived of the study, designed the methods, analyzed and interpreted the qualitative data, and wrote the manuscript. S.R. contributed to the design and supervised the project from design through implementation. All authors read and approved the final manuscript. Acknowledgements: We are grateful to Jenny Hong for her contribution as an external coder and to the Perelman School of Medicine Office of Student Affairs for provision of the anonymized data. References Osch M van, Dulmen S van, Vliet L van, Bensing J. Specifying the effects of physician’s communication on patients’ outcomes: A randomised controlled trial. Patient Educ Couns. 2017;100(8):1482–9. Sharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023 Aug 22;23(1):886. Street RL, Makoul G, Arora NK, Epstein RM. How does communication heal? 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How first-year medical students make sense of their learning experience in a traditional, preclinical curriculum. Med Educ Online. 2018 Jan 1;23(1):1500344. Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 08 Feb, 2026 Editor invited by journal 16 Jan, 2026 Editor assigned by journal 09 Jan, 2026 Submission checks completed at journal 08 Jan, 2026 First submitted to journal 08 Jan, 2026 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. We do this by developing innovative software and high quality services for the global research community. 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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-8512849","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589422131,"identity":"c5e09658-6190-428a-b962-bfb5b5c78b03","order_by":0,"name":"Julie Rebecca Wechsler","email":"data:image/png;base64,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","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":true,"prefix":"","firstName":"Julie","middleName":"Rebecca","lastName":"Wechsler","suffix":""},{"id":589422133,"identity":"dc124411-9d81-4a5c-823c-a9384dde5baf","order_by":1,"name":"Stacey Rose","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Stacey","middleName":"","lastName":"Rose","suffix":""}],"badges":[],"createdAt":"2026-01-04 12:08:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8512849/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8512849/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102491150,"identity":"d5c8c05c-36f8-40b8-9e1e-4f264d8c0c32","added_by":"auto","created_at":"2026-02-12 08:42:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":60126,"visible":true,"origin":"","legend":"\u003cp\u003eBreakdown of Interpersonal and Content items mentioned.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8512849/v1/5db4d8d4e5809c231bea9e2c.png"},{"id":102491468,"identity":"8005660d-ae2e-44e7-8113-a6e0874d16ea","added_by":"auto","created_at":"2026-02-12 08:43:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":903430,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8512849/v1/d7a4ac4a-fb4a-4aa9-945d-34f8c8a56fd5.pdf"},{"id":102491290,"identity":"194af3ac-1879-42f6-86bf-4d0ae4fdf71b","added_by":"auto","created_at":"2026-02-12 08:43:02","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":281427,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-8512849/v1/56e86224e63a42b31d8d96c3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating preclinical medical students’ self-perceived OSCE performance: Content versus interpersonal skills","fulltext":[{"header":"Background","content":"\u003cp\u003eEffective communication in medicine has been shown to improve patient-related experiences like satisfaction, trust, and understanding, which are in turn associated with better health outcomes (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Given the importance of good communication, the Accreditation Council for Graduate Medical Education (ACGME) prioritizes interpersonal and communication skills as a core competency for training physicians (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). A large body of research exists on training this competency, evaluating both in-person and virtual formats, and ranging from individual work with standardized patients to larger-group work (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Such training courses are generally found to have some positive effect on students\u0026rsquo; overall communication skills, empathy, and information gathering ability (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Simulation, as with the Objective Structured Clinical Examination (OSCE) format, is a frequently employed method, as it gives students experiential practice and individualized feedback (\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eClinical rotations are a rich opportunity for honing of communication and clinical reasoning skills (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). As a result, skills interventions are often conducted with clinical-level students, leaving students in the preclinical time somewhat underrepresented (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Yet the end of the preclinical phase of the curriculum is a fascinating inflection point, particularly with respect to clinical reasoning and interpersonal skills, two skills OSCEs are often designed to assess (\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). At our institution, an OSCE is completed at this moment before the transition to clinical clerkships. Afterward, students are asked to evaluate their performance via a self-rated interpersonal skills score and written reflection.\u003c/p\u003e \u003cp\u003eOn the one hand, students have just completed the basic science curriculum, which leans heavily toward building a base for clinical reasoning and would suggest that their focus at this time is on medical knowledge. On the other hand, as they wrap up their Doctoring and history-taking courses and mentally prepare to start on the wards, they may instead be pondering how to apply interpersonal skills to real patient interactions. In this study, we interrogate the balance between these two broad skillsets: in reflecting on an OSCE exercise, how do preclinical medical students perceive their performance in terms of the content of the interaction (medical knowledge) versus the delivery (interpersonal skills)?\u003c/p\u003e \u003cp\u003eIn asking these questions, it\u0026rsquo;s important to define these two categories carefully. Definitions for interpersonal skills vary, but most comprise both verbal and nonverbal behaviors (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Verbal behaviors include what students actually say; for instance, using suitable language, open-ended questions, empathic words, and summary statements (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Verbal behaviors help accomplish the provider\u0026rsquo;s objectives, but they can also influence the patient\u0026rsquo;s perception of the visit (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNonverbal behaviors also influence patients\u0026rsquo; experiences of the encounter (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Nonverbal behaviors are paralinguistic practices such as body orientation and body language (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e); gaze and eye contact (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e); facial expressions (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e); voice characteristics such as tone, speed, and volume (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e); touch (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e); and so-called unpurposive movements, such as touching one\u0026rsquo;s face or interacting with a pen or other object in the vicinity (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These play an important role in conveying empathy and emotion in all encounters, whether primarily medical-focused or psychosocial (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eVerbal and nonverbal behaviors can be assessed externally by observer ratings (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), or, less commonly, by students\u0026rsquo; qualitative self-perceptions (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). In contrast, the medical knowledge component is more often measured by formal assessments like case activities, written examinations, or oral examinations (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Increasingly, educators may attempt to link basic science concepts to clinical scenarios (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Nevertheless, an OSCE may be one of the first times where medical knowledge is experienced as a key part of the patient encounter, rather than a distinct entity.\u003c/p\u003e \u003cp\u003eReflecting on an OSCE therefore brings the two components, interpersonal (verbal and nonverbal) and medical knowledge, together. At this level, even if the primary goal of the OSCE might be to work on interpersonal skills, the medical knowledge is particularly salient, as these students are still learning the content. The goal of this study is to explore how students view the balance between these skills, and what they perceive to be their own strengths and areas of improvement in both regards.\u003c/p\u003e \u003cp\u003eIt is important for physicians to be able to assess their own performance once they are in practice, so it is also critical for students to begin to understand their own communication practices early on in training (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). The act of reflection is crucial not only for improving communication behaviors (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), but more broadly for forming a professional identity (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). At this point, students\u0026rsquo; own insights are a valuable glimpse into the minds of those who are just beginning to identify themselves as part of the medical profession.\u003c/p\u003e \u003cp\u003eReviewing self-assessments of preclinical students both details current communication practices and points to where students may need greater instruction at this level of training. Ultimately, this work aims to contribute to a more detailed understanding of how we can prepare students to be strong communicators as they transition to the clinical environment.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe OSCE format is employed throughout our institution\u0026rsquo;s curriculum, most notably at the end of each clerkship block (internal medicine, pediatrics, family medicine, surgery, emergency medicine, neurology, psychiatry, obstetrics/gynecology). At the end of the 18-month pre-clinical curriculum, second-year medical students participate in the Core 1 OSCE, which is their first exposure to the OSCE format and simulation center procedures. Afterward, they respond in writing to a prompt about their communication skills, and the resulting reflections were the data source for this work. We examined reflections of all students who took the Core 1 OSCE in the years 2023 and 2024. The prompt asked students to rate their interpersonal skills based on a provided checklist, then suggest strategies for improvement, without specifying whether they should answer with a content item or an interpersonal skill (see Appendix). This study was reviewed by the University of Pennsylvania IRB and given an exempt determination (protocol #859227). Per the Common Rule CFR 46.104, Category 4 (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), no consent was required given that the reflections were secondary data and completely deidentified.\u003c/p\u003e \u003cp\u003eWe conducted a mixed-methods study using a constructivist approach, acknowledging that conclusions are socially constructed, in contrast to the post-positivist view\u0026rsquo;s search for an objective truth (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). The data were reviewed using iterative thematic analysis. After an initial review of the reflections, tentative codes were identified and used to approach the codebook more deductively, regrouping the initial codes under the categories \u0026ldquo;interpersonal\u0026rdquo; (verbal and nonverbal) and \u0026ldquo;content.\u0026rdquo; Within these, we used the AAMC/ACGME core competencies (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and the interpersonal skills checklist (see Appendix) to refine the specific behaviors of interest. In the end, the \u003cem\u003eInterpersonal\u003c/em\u003e category included \u003cem\u003eEliciting Information, Listening, Giving Information, Respectfulness, Empathy\u003c/em\u003e, and \u003cem\u003eProfessionalism\u003c/em\u003e; the \u003cem\u003eContent\u003c/em\u003e category included \u003cem\u003eMedical Knowledge, Patient Care\u003c/em\u003e, and \u003cem\u003eSystems-Based Practice\u003c/em\u003e (see Appendix for full codebook and representative quotations).\u003c/p\u003e \u003cp\u003eConsensus coding was carried out to strengthen the themes and ensure intelligibility of the codebook. Approximately 10% of the reflections (30 total) were reviewed by a coder external to the project using the original codebook. Discrepancies were discussed and resolved with the primary researcher (J.R.W.). The updated codebook was then utilized to analyze the rest of the data, 288 reflections in total. This method combined the reflexive and coding reliability approaches which have been described in the literature (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e); though the coding process has an inherent degree of subjectivity, we wanted to ensure that the codebook organization and definitions made sense to someone unaffiliated with the project. After the initial coding of the text, each reflection was labeled as primarily \u003cem\u003eContent\u003c/em\u003e or primarily \u003cem\u003eInterpersonal\u003c/em\u003e based on their answer to the last question, \u0026ldquo;What new element would you address if you could repeat the encounter?\u0026rdquo;. If students did not explicitly say \u0026ldquo;If I could repeat the encounter, I would...\u0026rdquo;, this label was based on the overall paragraph.\u003c/p\u003e"},{"header":"Results and Discussion","content":"\u003cp\u003eSeveral major themes emerged from the student reflections of their Core 1 OSCE performance: 1. Interpersonal skills, 2. Content, 3. Finding balance, 4. Future. Of the 288 reflections analyzed, 193 (67%) focused on only interpersonal items, 38/288 (13%) focused only on content items, 55/288 (19%) talked about both interpersonal and content, and 2/288 (0.7%) did not state a future element to address. Sample quotations are provided, with the number of the student reflection provided in parentheses.\u003c/p\u003e\n\u003ch3\u003eInterpersonal skills\u003c/h3\u003e\n\u003cp\u003eThe majority of students focused on their interpersonal skills during the encounter. Subthemes of verbal and nonverbal skills emerged for most of the interpersonal skills checklist categories, though students more frequently talked about verbal skills than nonverbal (or paraverbal) skills, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Students who focused on interpersonal skills most frequently addressed the subthemes of \u003cem\u003eEliciting Information\u003c/em\u003e, followed by \u003cem\u003eGiving Information \u0026ndash; Verbal\u003c/em\u003e and \u003cem\u003eProfessionalism\u003c/em\u003e, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \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\u003eFrequency of mention of each \u003cem\u003eInterpersonal\u003c/em\u003e category (total number of students who focused on \u003cem\u003eInterpersonal\u003c/em\u003e: 193; total number of mentions of an \u003cem\u003eInterpersonal\u003c/em\u003e theme: 303).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterpersonal only\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of mentions (out of 303)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEliciting Information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGiving Information \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eListening \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespect/Empathy \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eListening \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespect/Empathy \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGiving Information \u0026ndash;\u003c/b\u003e \u003cb\u003eParaverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.6\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\u003eThe \u003cem\u003eEliciting Information\u003c/em\u003e category covered how students asked questions (open- versus close-ended, understandable versus unclear, stacking questions) as well as some example questions, such as assessing patient understanding and asking if the patients had any questions.\u003c/p\u003e \u003cp\u003eFor the \u003cem\u003eGiving Information \u0026ndash; Verbal\u003c/em\u003e category, students reflected on how well they explained information to their patients. This presented an interesting conundrum\u0026mdash;when students are still learning the material themselves, it can be a challenge to teach it appropriately, as one student described:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I struggle to allow myself to offer information to my SPs out of fear that my information (diagnoses, medication side effects, etc.) may be wrong or incomplete. As I continue to progress in my understanding, I need to remind myself to feel more confident sharing what I do know and being more comfortable explicitly acknowledging my limitations and letting them know I will be sure to ask more senior members of the care team for answers to those questions.\u0026rdquo; (#189)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn the same vein, many students mentioned a desire to share their reasoning with patients. This is consistent with the trend that medicine is shifting away from the paternalistic view it has been characterized by in the past; rather than telling patients what to do, doctors increasingly explain their thought processes and rationale for diagnostics and treatment (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn sharing information, though, students mentioned some occasions where they could have been clearer or provided more detail. They also occasionally overwhelmed the patient with information or came across as patronizing, which is perceived negatively by patients (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Many discussed their use of medical terminology, and how that landed with patients:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It felt tricky to summarize the medical jargon in a way that is easy to understand.\u0026rdquo; (#23)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think by using his medical diagnosis I confused him, and I may have made him feel incompetent for being confused. Thus, next time I will make sure to frame my questions more open-ended, with less medical jargon.\u0026rdquo; (#34)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I also want to practice more explaining complicated processes like heart failure in lay terms so that I feel more at ease communicating these things to patients.\u0026rdquo; (#61)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAccumulating medical terms is an inherent part of medical training, but using unfamiliar terms\u0026mdash;something providers are not always aware of doing\u0026mdash;might confuse the patient (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). On reflection, students learned to pay attention to their word choice.\u003c/p\u003e \u003cp\u003eThe counterpart of the \u003cem\u003eGiving Information \u0026ndash; Verbal\u003c/em\u003e category was \u003cem\u003eGiving Information \u0026ndash; Paraverbal\u003c/em\u003e, which refers to voice characteristics (pace, tone, volume, articulation, mumbling) and filler words such as \u0026ldquo;um\u0026rdquo; and \u0026ldquo;uh.\u0026rdquo; It has been widely acknowledged that communication skills trainings should include nonverbal skills (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Interestingly, this was the least-cited area for improvement, and the other \u003cem\u003eNonverbal\u003c/em\u003e subcategories were not brought up as often either. Though the lower numbers in our sample suggest that this area is a minor issue for most students, it did appear to be helpful for some students to recognize their verbal tics.\u003c/p\u003e \u003cp\u003e Professionalism was the third-most common area for improvement, along with its verbal and nonverbal sub-categories. For the \u003cem\u003eVerbal\u003c/em\u003e subcategory, students noted the importance of appropriate introductions, professional word choice, and logical progression of the visit. Many talked about using signposting phrases so patients understand what is coming next, as well as outlining a roadmap in their own minds to keep themselves on track. For the \u003cem\u003eNonverbal\u003c/em\u003e subcategory, students recognized how distracting behaviors can detract from the visit (e.g., facial expressions, fidgeting, playing with a pen), and how being rushed or flustered can negatively affect the patient\u0026rsquo;s experience. Relating these behaviors and their outcomes back to one's intent shows a growing self-awareness (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;My biggest point to fix is in being able to not let my own frustration with my questioning show up in my face. While it is understandable that we are still working on our history-taking, I need to remind myself that how I am delivering questions and receiving answers really matters in making the patient feel comfortable.\u0026rdquo; (#269)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnderstanding how one\u0026rsquo;s own behaviors influence another person\u0026rsquo;s experience of the interaction (positively or negatively) is key for productive communication (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStudents described the difficulty of staying engaged with the patient when dealing with the cognitive load of the situation. Whether it was that the OSCE format felt unfamiliar; thinking of what to ask next; or balancing asking questions, note-taking, appropriate eye contact and body language, students recognize that the multitasking involved in history-taking should not distract from being present with the patient:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Sometimes when my mind is distracted thinking about what to ask next, I can miss what my SP is telling me. This ends up affecting the connection that I could build with them and so it impacts our interaction.\u0026rdquo; (#72)\u003c/p\u003e\u003cp\u003e\u0026ldquo;In general, when I can just listen and don\u0026rsquo;t have to think about where I\u0026rsquo;m going to take the interview next, it\u0026rsquo;s easier for me to be fully present in the encounter. So I think having a better plan for the flow would make it easier for me to listen effectively. Of course, leaving room to deviate from the plan if needed.\u0026rdquo; (#83)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I was at time not engaged fully in the conversation because I was taking notes on what the patient was saying. This led to moments where the patient might have felt distant or unheard.\u0026rdquo; (#231)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne of the most common concerns, however, fell under the umbrella category of \u003cem\u003eProfessionalism\u003c/em\u003e, as it is neither fully verbal nor nonverbal: time management. Other students have also reported struggling with this (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). Here, they recognize that the time crunch they felt will be an all-too-common occurrence in their future careers:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;In clerkships and in the future I will have to become efficient taking histories and doing physical exams so it will be key to come in with a clear framework in my mind of what I want to do.\u0026rdquo; (#72)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Given that the OSCE was much more concise [than our] previous [Introduction to Clinical Medicine course] sessions, and I suspect the timing on the wards could also be tight, I will... lean more into guiding the conversation to inquire about necessary topics... while at the same time give space for the patient to tell their story.\u0026rdquo; (#147)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eRelatedly, students cited organization and structuring of the interaction as two other areas of improvement, which have also been described previously (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). To deal with this, they emphasized the need to be prepared before the visit and efficient during the interaction. Preparation is a careful balance, though. On one hand, knowing what questions to ask streamlines the interaction and offloads some of the cognitive burden; on the other hand, going too far in that direction might sound overly rehearsed, or make the conversation so inflexible that the conversation is no longer guided by the patient (as one student pointed out).\u003c/p\u003e \u003cp\u003eOur findings tie into the debate regarding the extent to which interpersonal skills can be taught (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Students come into medical school carrying unique personalities and experiences that influence how they interact with others, but experiential learning, personal reflection, and guidance from mentors also foster interpersonal skill development (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Given that reflection contributes to skill development, prompts need to be designed intentionally and clearly. Our findings show that the wording of the prompt likely encouraged students to contemplate their interpersonal skills.\u003c/p\u003e\n\u003ch3\u003eMedical content\u003c/h3\u003e\n\u003cp\u003eThough the assignment might have leaned more toward interpersonal skills, medical content was still highly represented. The 38 students who focused on \u003cem\u003eContent\u003c/em\u003e mentioned 44 content areas, with \u003cem\u003ePatient Care\u003c/em\u003e (18/44) and \u003cem\u003eMedical Knowledge\u003c/em\u003e (17/44) being the most common themes, followed by \u003cem\u003eSystems-Based Practice\u003c/em\u003e (9/44), as demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\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\u003eFrequency of mention of each \u003cem\u003eContent\u003c/em\u003e category (total number of students who focused on \u003cem\u003eContent\u003c/em\u003e: 38; total number of mentions of a \u003cem\u003eContent\u003c/em\u003e theme: 44).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContent only\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of mentions (out of 44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical Knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSystems-Based Practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20.5\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\u003eWithin \u003cem\u003ePatient Care\u003c/em\u003e, the majority focused on components of the social history that they had missed (e.g., asking about occupation, alcohol use, financial situation). A few discussed the fact that the instructions for the OSCE differed from what they were used to, so they were not always able to complete the objectives when they were less familiar (e.g., medication reconciliation, results follow-up, writing a note in a particular style).\u003c/p\u003e \u003cp\u003eUnder \u003cem\u003eMedical Knowledge\u003c/em\u003e, the vast majority of students noted that they should have elicited more specific information about patients\u0026rsquo; medications, such as dose, timing, frequency, and purpose. Several noted that they neglected to ask about diet, and a few wished they had discussed the patient\u0026rsquo;s diagnosis more. Though this code is closely related to the interpersonal \u003cem\u003eEliciting Information\u003c/em\u003e, here students only mentioned \u003cem\u003ewhat\u003c/em\u003e they wish they had asked, without discussing \u003cem\u003ehow\u003c/em\u003e they would have phrased or approached it.\u003c/p\u003e \u003cp\u003eFor \u003cem\u003eSystems-Based Practice\u003c/em\u003e, students spoke about resources and barriers to care. Many expressed a desire to be more familiar with the resources available to patients, as they felt unable to counsel adequately with their limited knowledge. Similar to the focus on instructions mentioned above, their limited familiarity with resources reminds us of how early these students are in their training. Some guidance (e.g., specific objectives for the session) helps focus the conversation, but too much emphasis on what they don\u0026rsquo;t yet know can instead distract from the interpersonal aspects of the conversation.\u003c/p\u003e\n\u003ch3\u003eOverlap between interpersonal skills and content\u003c/h3\u003e\n\u003cp\u003eA large proportion of students discussed both \u003cem\u003eInterpersonal skills\u003c/em\u003e and \u003cem\u003eContent\u003c/em\u003e items, with the most common subthemes shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Here we dive deeper into how students notice the overlap and grapple with the tensions between these two areas.\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\u003eFrequency of mention of each category when both \u003cem\u003eContent\u003c/em\u003e and \u003cem\u003eInterpersonal\u003c/em\u003e were brought up (total number of students who mentioned both: 55; total number of mentions of either theme: 128).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBoth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of mentions (out of 128)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePatient Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical Knowledge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEliciting Information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSystems-Based Practice\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGiving Information \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespect/Empathy \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRespect/Empathy \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eListening \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eListening \u0026ndash;\u003c/b\u003e \u003cb\u003eVerbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProfessionalism \u0026ndash;\u003c/b\u003e \u003cb\u003eNonverbal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.8\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\u003eSome students in this \u0026ldquo;Both\u0026rdquo; category listed separate skills to work on, but many tied them together. For example, several students mentioned that they\u0026rsquo;d like to improve time management so as to have time to dive into specific topics:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"If I could do it all over again, I would review the specific points that they want me to hit on, whether it is insurance or medication adherence or others, and try to focus on them during the encounter. I would try to write these down in an organized step-wise manner so that I can make sure to cover all of those goals before I run out of time.\" (#72)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLike the students who only mentioned \u003cem\u003eProfessionalism\u003c/em\u003e themes, this student emphasizes the interpersonal ideas idea of efficiency and organization (\u003cem\u003eProfessionalism\u003c/em\u003e) by highlighting specific content (\u003cem\u003eMedical Knowledge\u003c/em\u003e) details like insurance and medications.\u003c/p\u003e \u003cp\u003eSocial history topics (such as mental, emotional, and psychological state, or patients' support systems) also came up several times, with the intent of getting at the interpersonal dimension. The goal here was to connect with patients or understand them better:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I could ask him what other people could provide support to him in times of need. Asides from managing [his chronic condition], what does he value in his life and what is he passionate about? Understanding my patient\u0026rsquo;s goals, values, and preferences can help me develop a better longitudinal relationship with them... and allow me to give better counseling advice.\" (#138)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn addition to asking social history questions, there was overlap with information transfer, such as sharing information and asking about patient understanding. When these ideas were referenced nonspecifically, they were coded as \u003cem\u003eInterpersonal\u003c/em\u003e (under \u003cem\u003eGiving Information\u003c/em\u003e or \u003cem\u003eEliciting Information\u003c/em\u003e, respectively), but several students brought them up in the context of specific \u003cem\u003eContent\u003c/em\u003e details, too. Some students wanted to give clearer explanations on certain topics and fleshed out how they might have phrased things better (#76, 134). Others wanted to explore patients\u0026rsquo; understanding by describing their particular medical conditions, rather than stating so generally (#59, 83, 88).\u003c/p\u003e \u003cp\u003eIn each of these examples, students gave an interpersonal reason for mentioning a content area. This suggests recognition of both concepts as integral to the interaction, reflecting true engagement with the reflection exercise.\u003c/p\u003e\n\u003ch3\u003eBalance\u003c/h3\u003e\n\u003cp\u003eSo far, we have demonstrated that students recognize both the importance of and the intersections between interpersonal skills and medical content. A handful of students mentioned explicitly that there is a balance between interpersonal and content aspects broadly (#150, 245), but several others conveyed the same idea of balance within a single theme. For example, students tried to find the sweet spot between listening and giving information:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I was trying to strike a balance between listening to their story and what barriers to care they might experience while also trying to give helpful and practical advice to try and alleviate some of their problems and worries.\u0026rdquo; (#4)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWithin \u003cem\u003eGiving Information\u003c/em\u003e itself, there is also a balance, as each patient has a different knowledge base and there is limited time in the encounter:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I wondered if I should give her more information about each drug or be as general as I was. I thought that if I went too in-depth about each drug, she was going to be overwhelmed and was going to get lost. I want to continue developing the right balance between broad explanations and educating my patients well.\u0026rdquo; (#29)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I was trying hard to find a balance of providing information without being condescending.\u0026rdquo; (#121)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePatient education can include too much or too little information, but it also carries more or less emotional weight depending on the topic. For conversations about uncertain results or potential diagnoses, there is a compromise between focusing on the good news versus the bad news, making sure the patient is fully informed but also not unnecessarily frightened (#214, 259).\u003c/p\u003e \u003cp\u003eThere is a fine line, too, between giving patients space and making them uncomfortable. Though several students mentioned that they\u0026rsquo;d like to elicit patient concerns more often, one noted that it\u0026rsquo;s possible to go too far:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I think one thing I could do to improve my interpersonal skills would be to trust that the patient has raised all concerns and not ask too many times, which can lead to the patient getting worried.\u0026rdquo; (#98)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnderlying the effort to both give and elicit information appropriately is, once again, the idea of limited time. Students struggled with the tradeoff between empathy and efficiency; they want the patient to feel heard and comfortable sharing, but they also need to complete the encounter\u0026rsquo;s objectives. As with \u003cem\u003eGiving Information\u003c/em\u003e above, students debated how to give patients space to speak while also gathering all the details they sought:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;I am still finding the balance between letting the patient say all they need to without feeling rushed, while knowing I only have a certain amount of time to get the answers I need.\u0026rdquo; (#14)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I would like to find the balance between letting the patient\u0026rsquo;s concerns guide the conversation in order for there to be a better flow in the conversation, while also making sure I don\u0026rsquo;t forget to ask about certain things.\u0026rdquo; (#114)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I found it hard to balance getting all the information I needed, specifically when it came to medication reconciliation which is quite time consuming, while also focusing on the interpersonal aspects of the visit.\u0026rdquo; (#118)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I still struggle with avoiding stacking questions as I try to find the balance between efficiency of discussion and thoroughness of examination.\u0026rdquo; (#267)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eStudents talked about balancing open-ended and close-ended questions (#204), as well as eye contact versus note-taking (#22, 93, 146). One gave an interesting example of how overcorrection is part of the learning process:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;The first encounter, I asked many open-ended questions to grow my understanding of the SP\u0026rsquo;s situation, but by welcoming their long responses I ran out of time and did not ask all of the questions I wanted. In the second encounter, I tried to work on that and ended up asking many, quick, yes/no questions that did not allow for as much conversation. I think finding a balance will be important in my future interactions.\u0026rdquo; (#110)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOvercorrection also came up in discussions of emotional engagement:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Earlier in the year I felt like I could easily get too emotional, which caused me in future encounters to shut down so that I wouldn\u0026rsquo;t run the risk of literally breaking down in front of a patient. I felt like this round of encounters I was able to feel a lot more grounded and levelheaded to show empathy without going too crazy with it.\u0026rdquo; (#161)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThis student describes how their emotional involvement has shifted over time. The topic of how empathy changes in medical school is well-explored in the literature (\u003cspan additionalcitationids=\"CR50 CR51 CR52\" citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Relatedly, the mental toll of being a physician has been implicated in the development of burnout (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). This student\u0026rsquo;s example provides a glimpse into how one begins to reckon with these difficult aspects of training.\u003c/p\u003e \u003cp\u003eThe question of balance raises the debate of which is more foundational, medical information or interpersonal skills. One student suggested that the clinical skills come first, and interpersonal skills layer on top:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;One specific strategy that I can use to improve my performance is ensuring I am going through systematically... I think this will allow me to lean into the above interpersonal skills without worrying about missing a key question (because I know that I will hit it through my checklist). As a result, I hope to strike a balance of both strong interpersonal engagement but also thorough clinical practice.\u0026rdquo; (#150)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEarly in training, attempting to master the content is a large cognitive demand. It is difficult to put that aside to focus fully on interpersonal skills, especially when content examinations are front and center in the preclinical phase and students may be nervous about performing well in the upcoming clerkship year. One student (#68) demonstrated this very clearly\u0026mdash;they described how prior experiences (teaching in high school and college, volunteering in medical school) allowed them to feel more comfortable educating the patient and asking about barriers to care. Knowing what to ask about then opened up the space to focus on the delivery of the information (such as speech pace and being concise). This suggests that knowledge is foundational, and the interpersonal is an additional layer that can only be addressed once the knowledge is in place.\u003c/p\u003e \u003cp\u003eOn the other hand, at a time when knowledge is still building, one thing students have more experience with and control over is how they present themselves. Students can be there for patients even when they don\u0026rsquo;t have all the details, suggesting that perhaps the interpersonal skills solidify first before the clinical content should be added in.\u003c/p\u003e \u003cp\u003eIn reality, as this discussion of balance demonstrates, both explanations have merit. Interpersonal skills and content are intertwined and build on each other over time as students gain more clinical exposure.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eLooking to the future\u003c/h2\u003e \u003cp\u003eMany students situated the OSCE in the broader context of their medical training. Some looked ahead to being a clerkship student on the wards (#5, 29, 33, 72, 91, 96, 115, 129, 133, 147, 152, 184, 213), to being a practicing physician (#72, 128, 152, 154, 204, 227, 228, 245), or more generally to \u0026ldquo;the future\u0026rdquo; or having more experience (#9, 72, 88, 93, 95, 115, 133, 195, 256). They mentioned which skills are important for student doctors and practicing doctors to hone (e.g. making communication \u0026ldquo;easy and understandable\u0026rdquo; (#9)).\u0026rdquo; More clinical experience brings improved medical knowledge and self-confidence, which both bolster communication (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSeveral others instead called back to the past, realizing that they feel more comfortable now in the clinical setting and with history-taking (#33, 103, 116, 160, 161, 248):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Watching my recording again, I feel very impressed at how much I have grown since my first standardized patient encounter. I definitely see myself being more confident in the way I approach these encounters and, thanks to my growing repertoire of medical knowledge, I also feel more confident in the questions that I am asking.\" (#248)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few also rightfully pointed out that the clinical environment is still new and they are still learning (#117, 258, 269). Framing their development over a longitudinal career demonstrates the ability to envision themselves as a future physician, which is an essential component of reflection (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) and professional identity formation (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnother overarching theme that students cited as important for the future was an increased awareness of these skills in general and increased insight into how they may be perceived. Several students (24/288) shared instances of their actions coming across differently than intended; sometimes more positively, and sometimes more negatively.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;There were times when my affect was very animated in an attempt to show that I was actively listening and to demonstrate empathy. However, my SP let me know that this strategy did not always hit the mark. In fact, they mentioned that it can come across as condescending at times.\u0026rdquo; (#41)\u003c/p\u003e\u003cp\u003e\u0026ldquo;The SP told me that they really appreciated when we stepped back from talking about their medical condition; during the encounter, I was a bit worried that this tangent might take time away from gathering more information/doing a full medicine reconciliation, but contrary to my fear, it gave the patient more comfort overall.\u0026rdquo; (#64)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I was trying hard to find a balance of providing information without being condescending. I think this could be a really tricky line to balance but the SP told me she didn\u0026rsquo;t perceive as condescending but helpful.\u0026rdquo; (#121)\u003c/p\u003e\u003cp\u003e\u0026ldquo;While I normally sit near the patient as a means of establishing rapport, she later told me that this made her feel a little bit nervous. In watching it back, I didn\u0026rsquo;t feel like I was encroaching on her, however that makes it even more critical to put on my radar.\u0026rdquo; (#133)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn recognizing that their actions may not be perceived as intended, students begin to realize that they must pay close attention to how they speak and carry themselves in the clinical context. They frequently referenced having to be more \u0026ldquo;cognizant\u0026rdquo; (#58, 76, 84, 133) of their behaviors, making a \u0026ldquo;conscious\u0026rdquo; (#35, 40, 59, 89, 106) or \u0026ldquo;conscientious\u0026rdquo; (#96) effort, or \u0026ldquo;purposely\u0026rdquo; (#95) adjusting how they interact. Students thus acknowledge their own agency in developing good habits. However, continual external feedback like this exercise is an important component of that process.\u003c/p\u003e \u003cp\u003eIn reflecting on what elements of a clinical encounter they would change in the future, students mostly focused on interpersonal skills, but many also tied in specific content areas or highlighted content alone. In the following section, we discuss the implications of these findings and the importance of reflection at this stage of medical training.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe purpose of this study was to examine preclinical medical students’ perceptions of their performance in an OSCE exercise with a specific focus on how they view interpersonal skills versus content. In line with prior research (33), students were able to report on their communication skills and why they are important. Here, the main takeaway was that while preclinical students recognize both categories of skills, their reflections skew toward interpersonal topics more than content.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne might have hypothesized that there would be greater emphasis on content, given that students are deep into the basic science curriculum and preparation for clerkships. There are a few possible explanations for why they tend to bring up interpersonal skills more often. First, although the wording of the reflection prompt did not specify what to focus on, they might have been primed to think about interpersonal skills from the first part of the assignment, which was to rate their interpersonal skills based on a rubric. Second, the thought of working with real patients soon—something they have not yet had much practice with—might have attuned students more to the interpersonal aspect of the conversation. But most interestingly, a significant proportion of students talked about both, indicating that even at this early stage of training, they are seeing how the skills overlap and build on each other.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn all of the topics raised, another main takeaway is that students at this level are starting to experience the push and pull of communicating as a physician.Preclinical students are learning multiple tasks at once, each of which requires mental energy. According to the cognitive load theory, given the limitations of our working memory, learners (novices in particular) may have difficulty managing simultaneous tasks (58). The theme of balance in our sample, as well as students’ examples of overcorrection, demonstrates that learning is often a matter of trial and error. Perhaps students only addressed one topic at a time because of the cognitive load; this theory reminds us that space must be dedicated to practicing both interpersonal and content areas, rather than a sole focus on one or the other.\u0026nbsp;As students begin to observe patterns, it is crucial for clinician teachers to connect interpersonal skills and content intentionally to help students learn to balance these competing needs\u0026nbsp;(59).\u003c/p\u003e\n\u003cp\u003eThat kind of external feedback is important for addressing areas of improvement (33). This was supported by the fact that some topics were raised based on the SP’s feedback. However, most topics came up from students observing their own behavior, highlighting that personal reflection is essential for trainees.Preclinical students have few real-life patient experiences to reflect upon (36); an OSCE simulation, though not a perfect rendering, allows them to practice the crucial skill of self-reflection. Thinking about what is or is not said, how it is said, who is involved, and how each party will react informs communication practices in the future (35). Use of medical jargon is a good example; as these students came to understand, using plain language is particularly important for different levels of health literacy (60), but it is also critical when working with interpreters for languages other than English (61) and just good practice for any patient. This OSCE made students listen to their own words carefully, which informs how they speak with patients moving forward.\u003c/p\u003e\n\u003cp\u003eThe reflection exercise was also helpful in that it gave students space to imagine themselves as future providers (62). Our focus on the preclinical phase of the curriculum was intentional because the transition from lecture hall as classroom to the hospital as classroom is an important milestone on the journey of professional identity formation (16). As previously described, our students’ reflections (particularly through writing) helped them situate the exercise in the broader context of medical training and professional identity development (36,37,57,63). Our work underscores the notion that reflection should be introduced early in medical training and remain part of a physician's lifelong professional development (44,64), as the ability improves with practice (56). From the student perspective, viewing their career longitudinally even at this stage reminds us that communication skill building is an iterative process. From the educator’s perspective, we know that effective reflection requires a supportive environment and mentorship (36). As we continuously evaluate medical school curricula, it is imperative to ensure not only opportunities to reflect but faculty support thereof.\u003c/p\u003e\n\u003cp\u003eThis study had a few limitations. Given the mandatory nature of the reflection assignment and competing time demands, some students may not have fully engaged in true reflection. The assignment was also based on self-evaluation, and prior work has demonstrated that trainees’ self-ratings do not always correlate with external evaluations\u0026nbsp;(18,34,65–68). Additionally, we must acknowledge that the OSCE format, though useful for maintaining consistency across student interactions, is inherently somewhat artificial (19,69). Real patients assess communication differently than providers and trainees do (69), so it is critical to evaluate communication skills in real-world scenarios, too.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are several avenues of further research that could stem from this work. The reflections assessed in this study were completed after the interaction occurred, which is a commonly used method to develop self-awareness and communication strategies (35). However, this is not the only time point which would be useful; in a future study, students could reflect on communication skills before participating in the OSCE, revealing which skills they are aware of at baseline. It would also be informative to conduct a similar exercise with more advanced students or even residents, since after the preclinical period, formal communication skills curricula decrease while real-world experiences increase (70). Examining how skills change over time would be an interesting example of portfolio learning, the iterative process of collecting experiences, reflection, and feedback and returning to these throughout training (44,71), illustrating whether skill development is more of a conscious evolution or something that comes with experience.\u003c/p\u003e\n\u003cp\u003eHere our focus was on what students need to improve, but it would also be informative to dive deeper into what they felt their strengths were and how their comments correlated with SP comments. Trends may vary based on experiences prior to medical school or anticipated specialty. As medical education explores more personalized curricula, this might help tailor communication trainings to individual students.\u003c/p\u003e\n\u003cp\u003ePart of what makes a good physician, in preclinical medical students’ eyes, is being a good communicator (72). This study’s focus on interpersonal and content skills informs how we design clinical skills education in general. Since content knowledge is necessary for effective communication, we must continue to pinpoint when students have enough content to perform effective interpersonal skills, and relatedly, to what extent we can teach interpersonal skills before that content baseline is achieved. We challenge educators to incorporate reflection early and periodically in pursuit of these goals. In considering the balance of these skills, we hope that early medical students may start building a foundation to be excellent communicators throughout their careers. \u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e- OSCE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eObjective Structured Clinical Examination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003e- SP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStandardized Patient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/em\u003eThis study was conducted in accordance with the norms of the Declaration of Helsinki. It was reviewed by the University of Pennsylvania Institutional Review Board, under the University of Pennsylvania Human Research Protections Program. It was deemed exempt (protocol #859227) given that the study design consisted of secondary use of deidentified data. Consent was deemed unnecessary given the completely deidentified nature of the reflections, per the Common Rule (45 CFR 46.104, Category 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eReflections were completely deidentified, so consent was not applicable. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003eThe qualitative data analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests:\u003c/em\u003e The authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding:\u0026nbsp;\u003c/em\u003eNo funding source exists for this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors' contributions:\u003c/em\u003e J.R.W. initially conceived of the study, designed the methods, analyzed and interpreted the qualitative data, and wrote the manuscript. S.R. contributed to the design and supervised the project from design through implementation. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003eWe are grateful to Jenny Hong for her contribution as an external coder and to the Perelman School of Medicine Office of Student Affairs for provision of the anonymized data. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOsch M van, Dulmen S van, Vliet L van, Bensing J. Specifying the effects of physician\u0026rsquo;s communication on patients\u0026rsquo; outcomes: A randomised controlled trial. Patient Educ Couns. 2017;100(8):1482\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eSharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023 Aug 22;23(1):886.\u003c/li\u003e\n\u003cli\u003eStreet RL, Makoul G, Arora NK, Epstein RM. 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MedEdPORTAL. 12:10455.\u003c/li\u003e\n\u003cli\u003eCvengros JA, Behel JM, Finley E, Kravitz R, Grichanik M, Dedhia R. Breaking Bad News: A Small-Group Learning Module and Simulated Patient Case for Preclerkship Students. MedEdPORTAL. 12:10505.\u003c/li\u003e\n\u003cli\u003eReid JR, Stone KP, Meyer EC. Simulation for Teaching Communication Skills. In: Grant VJ, Cheng A, editors. Comprehensive Healthcare Simulation: Pediatrics [Internet]. Cham: Springer International Publishing; 2016 [cited 2025 Oct 4]. p. 291\u0026ndash;8. Available from: https://doi.org/10.1007/978-3-319-24187-6_23\u003c/li\u003e\n\u003cli\u003eSedler J, Cohen H, Sourkes B, Hollander S, Rassbach CE. Teaching Pediatrics Residents a Communication Framework for Delivering Difficult News: A Randomized Controlled Trial of Practice Methods. Acad Pediatr. 2025 May 1;25(4):102802.\u003c/li\u003e\n\u003cli\u003eTalwalkar JS, Fortin AH, Morrison LJ, Kliger A, Rosenthal DI, Murtha T, et al. An Advanced Communication Skills Workshop Using Standardized Patients for Senior Medical Students. MedEdPORTAL. 17:11163.\u003c/li\u003e\n\u003cli\u003eLurie SJ, Meldrum S, Nofziger AC, III LFS, Mooney CJ, Epstein RM. Changes in self-perceived abilities among male and female medical students after the first year of clinical training. Med Teach [Internet]. 2007 Jan 1 [cited 2025 Aug 21]; Available from: https://www.tandfonline.com/doi/full/10.1080/01421590701753559\u003c/li\u003e\n\u003cli\u003eIsaksson J, Krabbe J, Ramklint M. Medical students\u0026rsquo; experiences of working with simulated patients in challenging communication training. Adv Simul. 2022 Oct 10;7(1):32.\u003c/li\u003e\n\u003cli\u003eRoshal JA, Chefitz D, Terregino CA, Petrova A. Comparison of self and simulated patient assessments of first-year medical students\u0026rsquo; Interpersonal and Communication Skills (ICS) during Objective Structured Clinical Examinations (OSCE). BMC Med Educ. 2021 Feb 17;21(1):107.\u003c/li\u003e\n\u003cli\u003eDaniels VJ, Pugh D. Twelve tips for developing an OSCE that measures what you want. Med Teach. 2018 Dec 2;40(12):1208\u0026ndash;13.\u003c/li\u003e\n\u003cli\u003eHa MT, Siddiqui ZS. Understanding medical students\u0026rsquo; transition to clinical training: a qualitative study of transformative learning and professional identity formation. BMJ Open. 2025 June 17;15(6):e098675.\u003c/li\u003e\n\u003cli\u003eSim JH, Aziz YFA, Mansor A, Vijayananthan A, Foong CC, Vadivelu J. Students\u0026rsquo; performance in the different clinical skills assessed in OSCE: what does it reveal? Med Educ Online. 2015 Jan 1;20(1):26185.\u003c/li\u003e\n\u003cli\u003eGraf J, Loda T, Zipfel S, Wosnik A, Mohr D, Herrmann-Werner A. Communication skills of medical students: survey of self- and external perception in a longitudinally based trend study. 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Available from: https://www.ecfr.gov/current/title-45/part-46/section-46.104\u003c/li\u003e\n\u003cli\u003eBrown MEL, Due\u0026ntilde;as AN. A Medical Science Educator\u0026rsquo;s Guide to Selecting a Research Paradigm: Building a Basis for Better Research. Med Sci Educ. 2019 Dec 27;30(1):545\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eAssociation of American Medical Colleges (AAMC), American Association of Colleges of Osteopathic Medicine (AACOM), Accreditation Council for Graduate Medical Education (ACGME). Foundational Competencies for Undergraduate Medical Education. 2024;\u003c/li\u003e\n\u003cli\u003eBraun V, Clarke V. Thematic Analysis. In: Encyclopedia of Quality of Life and Well-Being Research [Internet]. Springer, Cham; 2022 [cited 2025 Sept 29]. p. 1\u0026ndash;7. Available from: https://link.springer.com/rwe/10.1007/978-3-319-69909-7_3470-2\u003c/li\u003e\n\u003cli\u003eStivers T, Tate A. The Role of Health Care Communication in Treatment Outcomes. Annu Rev Linguist. 2023 Jan 17;9(1):233\u0026ndash;52.\u003c/li\u003e\n\u003cli\u003ePitt MB, Hendrickson MA. Eradicating Jargon-Oblivion\u0026mdash;A Proposed Classification System of Medical Jargon. J Gen Intern Med. 2020 June 1;35(6):1861\u0026ndash;4.\u003c/li\u003e\n\u003cli\u003eHulsman RL, Harmsen AB, Fabriek M. Reflective teaching of medical communication skills with DiViDU: Assessing the level of student reflection on recorded consultations with simulated patients. Patient Educ Couns. 2009 Feb 1;74(2):142\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLiu C, Calvo RA, Lim R. Improving Medical Students\u0026rsquo; Awareness of Their Non-Verbal Communication through Automated Non-Verbal Behavior Feedback. Front ICT [Internet]. 2016 June 20 [cited 2025 Oct 10];3. Available from: https://www.frontiersin.org/journals/ict/articles/10.3389/fict.2016.00011/full\u003c/li\u003e\n\u003cli\u003eKurtz S, Silverman J, Draper J. Teaching and Learning Communication Skills in Medicine, Second Edition. 2nd ed. Boca Raton: CRC Press; 2016. 1 p.\u003c/li\u003e\n\u003cli\u003eBaernstein A, Oelschlager AMEA, Chang TA, Wenrich MD. Learning Professionalism: Perspectives of Preclinical Medical Students. Acad Med. 2009 May;84(5):574.\u003c/li\u003e\n\u003cli\u003eBurnard P. Acquiring Interpersonal Skills: A Handbook of Experiential Learning for Health Professionals. Springer; 2013. 246 p. \u003c/li\u003e\n\u003cli\u003eFerreira-Valente A, Monteiro JS, Barbosa RM, Salgueira A, Costa P, Costa MJ. Clarifying changes in student empathy throughout medical school: a scoping review. Adv Health Sci Educ. 2017 Dec 1;22(5):1293\u0026ndash;313.\u003c/li\u003e\n\u003cli\u003eHowick J, Dudko M, Feng SN, Ahmed AA, Alluri N, Nockels K, et al. Why might medical student empathy change throughout medical school? a systematic review and thematic synthesis of qualitative studies. 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Health Aff (Millwood). 2010 July;29(7):1310\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRees C, Sheard C. Undergraduate medical students\u0026rsquo; views about a reflective portfolio assessment of their communication skills learning. Med Educ. 2004;38(2):125\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eSchei E, Johnsrud RE, Mildestvedt T, Pedersen R, Hj\u0026ouml;rleifsson S. Trustingly bewildered. How first-year medical students make sense of their learning experience in a traditional, preclinical curriculum. Med Educ Online. 2018 Jan 1;23(1):1500344.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"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":"preclinical medical students, OSCE, reflection, interpersonal skills, medical knowledge","lastPublishedDoi":"10.21203/rs.3.rs-8512849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8512849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEffective communication is a key skill for medical trainees (Correa et al. 2025). This requires both knowledge and interpersonal skills. The former is obviously a major component of medical school curricula, but the latter is also increasingly taught intentionally (Flanagan \u0026amp; Cummings 2023; Gilligan et al. 2021). Objective Structured Clinical Examinations (OSCEs), which give students experiential practice and individualized feedback, are frequently used to this end (Brogan et al. 2016; Cvengros et al. 2016; Reid et al. 2016; Sedler et al. 2025; Talwalkar et al. 2021). At our institution, an OSCE is completed at the end of the preclinical phase of medical school, which is a fascinating inflection point in the curriculum; students have been learning clinical reasoning and interpersonal skills through their coursework, but they have yet to apply them to real patient encounters. In this study, we analyze written reflections composed after this OSCE to interrogate the balance between these two skillsets: to what extent do preclinical medical students turn their focus to the content of the interaction (medical knowledge) versus the delivery (interpersonal skills)?\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eSecond-year medical students completed an OSCE exercise and written reflection. The resulting 288 reflections were analyzed using a thematic analysis framework. Codes were identified based on common competencies assessed in learners and categorized as either \u0026ldquo;interpersonal\u0026rdquo;- or \u0026ldquo;content\u0026rdquo;-related.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAnalysis revealed that students see room for improvement with both interpersonal skills and content areas, highlighting behaviors that are important but not yet mastered. There was greater focus on interpersonal than content, but many students described how the two intertwine in a medical encounter. Major themes included the idea of balance and looking to the future, as well as the importance of reflection in professional identity formation.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003ePreclinical medical students are able to reflect on the balance between interpersonal skills and medical content. Detailing their current practices informs where they may need greater instruction. Ultimately, this work aims to contribute to a more detailed understanding of how we can prepare students to be strong communicators as they transition to the clinical environment.\u003c/p\u003e","manuscriptTitle":"Evaluating preclinical medical students’ self-perceived OSCE performance: Content versus interpersonal skills","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-12 08:41:01","doi":"10.21203/rs.3.rs-8512849/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2026-02-09T03:31:54+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-16T06:59:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-09T06:22:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-08T15:50:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2026-01-08T15:39:26+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":"d736fdc1-15de-4299-87c2-d2edb6108242","owner":[],"postedDate":"February 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-12T08:41:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-12 08:41:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8512849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8512849","identity":"rs-8512849","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}