Clinical performance of medical students in a whole-task emergency station for the objective structured clinical examination with the standardized patient who complains of palpitation in Korea

Clinical performance of medical students in a whole-task emergency station for the objective structured clinical examination with the standardized patient who complains of palpitation in Korea Song Yi Park1,5, Hyun-Hee Kong2, Min-Jeong Kim3, Yoo Sang Yoon4, Sang-Hwa Lee5, Sunju Im6, JiHyun Seo7 1Department of Emergency Medicine, College of Medicine, Dong-A University, Busan, Korea; 2Department of Parasitology, College of Medicine, Dong-A University, Busan, Korea; 3Department of Medical Education and Neurology, Kosin University College of Medicine, Busan, Korea; 4Department of Emergency Medicine, Inje University College of Medicine, Busan, Korea; 5Department of Medical Education, College of Medicine, Dong-A University, Busan, Korea; 6Department of Medical Education, Pusan National University School of Medicine, Busan, Korea; 7Department of Pediatrics and Medical Education, Gyeongsang National University School of Medicine, Jinju, Korea

Background/rationale: Palpitations are a common clinical presentation in patients who visit the emergency department (ED). The etiology of palpitations ranges from benign factors to life-threatening cardiac problems. Electrocardiography (ECG) is a non-invasive and applicable diagnostic tool that can be used at the patient's bedside [1]. Students' competency in performing structured and fast patient assessments and performing ECG studies should be acquired and assessed during undergraduate medical education.
In the clinical skill portion of the Korean Medical License Examination (KMLE), palpitations are considered one of 54 clinical presentations of the standardized patient (SP) encountered during the objective structured clinical examination (OSCE). Furthermore, ECG is one of 32 procedural skill tests (suppl. 1). In general, SPs can simulate symptoms of palpitations but cannot reproduce abnormal physical examination or ECG results. Thus, skills required during encounters of an SP (history taking, physical examination, diagnostic workup planning) and performing ECG studies used to be evaluated as a partial task in isolation. However, in real clinical contexts in the ED, the physician takes the patient history and performs the physical examination and ECG study simultaneously to differentiate the cause of palpations as a whole-task. There were studies on the advantages of whole-task OSCE [2,3]. However, few studies have reported clinical performance in whole-task emergency case OSCE station of a medical student.
Objectives: Therefore, we had a research question "How are the clinical performance of medical students in a whole-task emergency case station for OSCE with standardized patient who complains of palpitation?". The purpose of this study was to examine the clinical performance of third-year medical students in a whole-task emergency case OSCE station that simulates a patient visiting the ED due to sustained palpitations.

Methods
Ethics statement: This study was approved by the institutional review board of Dong-A University (IRB approval no., 2-1040709-AB-N-01-202002-HR-003-02). Informed consent was waived because subjects participated in the examination as a scheduled educational curriculum.

Study design:
This is a cross-sectional observational study.
Participants: A total of 150 third-year medical students who attended the first day of the Busan-Gyeongnam Clinical Skill Examination (BGCSE), which was summative and mandatory, were included in this study.
Setting: The BGCSE Consortium is an association of 5 medical schools in the Busan-Gyeongnam region in South Korea that have conducted joint clinical skill examinations for the OSCE for 3rd-year medical students annually since 2014. In 2019, a whole-task emergency case OSCE station was developed by faculty members from 5 medical schools, including 2 emergency physicians, 1 pediatrician, 1 neurologist, and 2 medical education experts who attended 5 half-day workshops. The examination was conducted with 11 other traditional OSCE stations (6 SP encounters and 5 technical skills) at the skill centers of four medical schools in Busan from November 25 to 27, 2019. The students were allowed 10 minutes at each station, and a 5-minute interval was allowed between stations.
The scenario involved a 28-year-old male with palpitations. He had palpitations occasionally; the palpitations usually lasted approximately 10 minutes, and they suddenly started and abruptly ended. He visited the ED after the palpitations lasted for an hour, which was considered unusual, earlier that day. The SPs were trained by an SP trainer about the scenarios for two hours and rehearsed for standardization for another two hours. All the SPs had more than 5 years of SP experience for the BGCSE. Four experienced faculty members from 4 medical schools volunteered to be examiners.
Briefings about the scoring rubrics, how to mark the scores using the computer programs, and the importance of confidentiality were conducted at the orientation held for the examiners.
The setting of the station is shown in Fig. 1. The SP was first interviewed by the student and then laid on the bed for a physical examination and ECG study. ECG electrodes were placed on the SP by a student, and an assistant provided the prepared normal ECG results. The students were informed about the whole-task station at their BGCSE orientation.
Measurement: The instructions provided to the students (outside the station) were as follows: "you are the primary physician in the ED; you are expected to take a history from this patient; perform a focused physical examination; select an appropriate diagnostic tool and perform the evaluation; develop a treatment plan with the patient and educate the patient; and write down the most probable diagnosis after the station is completed". Clinical performance for history taking and the physical examination: For history taking, the performance rate was the highest for checklist item 3 (98.7%, check whether the patient has a previous history of palpitations) and the lowest for checklist item 9 (23.3%, accompanied by a loss of consciousness) ( Table   1). In the physical examination, 18.0% of students checked the patient's pulse (Table 2). Raw data are available from Dataset 1. Clinical performance for the ECG study: There were 93 (62.0%) students who tried an ECG study and 57 (38.0%) students who did not even attempt an ECG study (Table 3). Clinical performance for patient education and clinical reasoning Forty-two (28.0%) students explained the ECG results to the patient (Table 4). Of the 69 students who completed the ECG study, 40 (57.9%) explained the ECG results to the SP. A total of 98% of the students reported paroxysmal supraventricular tachycardia (PSVT) as the most likely diagnosis. Key results: This study examined the clinical performance of third-year medical students in a whole-task emergency case OSCE station where an ECG study was performed for an SP complaining of palpitations in a simulated ED. The main findings were that a third of students did not attempt an ECG study and focused on taking a detailed patient history and performing a non-emergent physical examination to rule out non-cardiac causes of palpitations, even though the ECG was prepared next to the patient's bed (Fig.   1).
Interpretation: The key point in this whole task case was to check if the patient has a palpitation now and to differentiate the fatal arrhythmia first. Students listened to the patient's detailed and non-urgent medical history, as was the case with the existing SP encounter partial task. This will be because we separated, educated and evaluated SP encounter skill (palpitation) and procedural skill (ECG study) so far.
Also, students would have had a basic assumption that the SP would not be able to simulate their palpitation at the OSCE station. The fact that students can do partial tasks does not seem to guarantee that they can do the whole task. And clinical skills seem to need to be acquired with abundant clinical context. While this study did not compare whether the OSCE design (whole vs partial task) affects students' learning strategies, the whole task OSCE appears to have an advantage in controlling preassessment learning.
Comparison with previous studies: To the best of our knowledge, we could not find a study on the ECG performance rate of medical students in whole-task emergency case OSCEs. Few studies about emergency case OSCEs have been tried [4], and the ECG study was designed as a partial task station in the emergency case OSCE composed of 6 whole-task stations and 4 traditional technical-skill stations [5].
In a hybrid station that tried whole-task OSCE combined an SP encounter and a simulated Papanicolaou test for a CSE, the results showed that the station was highly authentic, acceptable, and feasible [6].
However, the study compared a new station with a traditional one, did not report the student's clinical performance. According to the studies reporting the whole-task OSCE, it increases students' use of diagnostic reasoning skills during the study period [2]. Whole-task OSCEs might make students use different learning strategies compared with that partial and fixed task OSCE stations which leads to the compartmentalization of certain skills for the examination [3,7]. Cilliers et al. proposed these findings and educational effects as a model of the pre-assessment learning effect [8].
Limitations: First, only 1 case may not be enough to assess students' clinical performance level. The medical students' clinical performance in this study cannot be inferred as their future competence in a workplace [9]. Second, the responses of the students and examiners in this study have not been investigated in depth. Third, 10 minutes would not have been enough for students to examine patients.
Forth, some students may have performed an ECG study, noticing that the ECG was ready at the station.
We have not assessed how many students conduct an ECG study.
Conclusion: Few studies have assessed whole-task emergency case OSCE stations performed by medical students. The clinical performance of third-year medical students at a whole-task emergency station was fair regarding history taking and clinical reasoning but unsatisfactory regarding the physical examination, ECG study, and patient education. It is necessary to strengthen physical examination, procedural skills, and patient education in preparation for the revised clinical skills test of KMLE.