Study design and participants
A summary of the study profile is shown in Fig. 1. We recruited first-year residents who required a three-month rotation in the head and neck surgery department of our hospital from September 2019 to September 2020. The inclusion criteria were as follows: 1) first-year residents who have not rotated to other surgical departments and 2) those who have completed a bachelor of medicine. The exclusion criteria were as follows: 1) residents who had been transferred to other surgical departments before the study; 2) senior residents (work time ≥ 1 year); 3) residents with a graduate degree; 4) residents who have obtained the clinical practitioner qualification certificate. After selection, a total of 87 residents were selected as research objects. They were divided into eight subgroups in order of rotation, and the subgroups were randomly sorted into a traditional teaching (the control) group (n = 42) or an SDTM group (n = 45 ) using a web-based randomization program. All had passed the entrance test, which served as a baseline assessment, and they would take the CMLE 9 months after the rotation ended. Participation was voluntary and informed consent was obtained. The students did not know which group they were randomly assigned to and the teacher grading the students did not know which group they belonged to. Participants were assured that all data would be treated anonymously. Each subgroup contained an SDTM and the control group, and there were three to six members in each of the two groups. Each subgroup was supervised by the tutoring group consisting of two instructors who held full-time professional positions within the Head and Neck Surgery Department and three assistants. Teachers who graded residents included two professionals (who graded the exam objectively) and four clinical teachers (who graded clinical performance subjectively). They did not participate in the teaching process and had a professional title above the position of senior associate. They were all practicing clinicians. The study was approved by the Institutional Review Board and Ethics Committee of West China Hospital of Sichuan University.
Preparation for anamnesis formation
First, four scripts were written for a standardized patient composed of two instructors holding SP training certificates. Second, a standard medical history taking video (about 15 minutes) was recorded based on acute suppurative tonsillitis, which did not belong to the above scripts. Third, an email containing the video recorded above and a PDF of the anamnesis scoring standards was sent to all participants three days before the training course. The SPs knew the scripts and had rehearsed at least once with a senior resident before class. The SDTM and the control group were asked to watch the video at least once and review the PDF file to understand the critical point of the anamnesis.
Other Preparation for Introductory Clinical Skills Training
First of all, the instructor prepared impeccable CST videos (about 8 minutes) on cardiopulmonary resuscitation, debridement and dressing change, disinfection, setting up drapes in the operating area, the wearing and removing the surgical gown and wearing sterile gloves. These videos have been implemented in accordance with CMLE guidelines. Second, there is a critical point in this study called “points of difference design.” Points of difference (DP) were error-prone points that are often overlooked in day-to-day clinical skill operations. The DPs were discussed and decided by the members of the teaching group. Approximately three DPs were arranged for display in each standard video (Table 1). These videos containing the DPs were a one-to-one match to the standard videos, and the same performers recorded the faulty videos in the same settings. Finally, three days before the course, the residents of the same subgroup received an email containing a PDF of the checklist of the points on the functioning of the skills and the flawless videos. Each standard video was sent in an orderly fashion according to the schedule of the program. Both groups had to watch the video at least once and review the critical points checklist for each operation.
Since the start of the rotation, CST courses have been held every two weeks. The length of each class varied slightly depending on the number of students, averaging about 120 minutes per group. The control group and the experimental group were placed in separate rooms because all participants were asked to be discreet about the details of their training and not to disclose them to their fellow citizens. The course was organized in the following order: anamnesis, cardiopulmonary resuscitation, dressing change, disinfection and placement of the operating field in the operating area, wearing and removing the surgical gown and sterile gloves.
History Training Program
Members of the SDTM group were randomly ranked and a printed scoring sheet whose content was the same as the previous PDF was distributed to everyone before the start of class activities. Next, the attendant performed a standard patient history process. Each resident performed a scenario selected from the four prepared scenarios. The remaining members were asked to observe the process and mark the gaps on the scoring sheet when they thought they had spotted the difference from the standard procedure. There are a few examples of PDs related to taking a medical history shown in Table 1. Additionally, if they observed some items where the candidate performed better than the standard responses, they could note those as well. Each resident received all feedback from other members at the end of the course, and the instructor summarized the course and reviewed common errors raised during that course.
The preparation of the control group before the course was the same as that of the experimental group while they were taught traditionally. Each trainee was individually trained. This training took place in a quiet room with only the trainee, the SP and the instructor. The instructor noted their performance, pointed out common weaknesses and offered suggestions for improvement on the spot.
The Introductory Clinical Skills Training Program
A manikin was used for clinical skills training in both groups. Prior to their clinical skills training, the SDTM group watched the video containing the PDs, while the control group watched the previous standard video. The control group and the experimental group received individual training in random order. Members of the SDTM group had to quickly mark the faulty point on the scoring sheet when they noticed the difference from the standard procedure. After that, each resident performed the skill operation individually, and the trainee was asked to say aloud how to use the changed skill when he came to a different point. If certain differences were not detected or if other malfunctions existed, the instructor would inform the corresponding participant at the end of the course.
In the control group, the instructor conducted the skills training following the previously recorded standard video guidance and provided individualized feedback at the end of the training.
Measurement of results and statistical analysis
Bidirectional subjective assessment between students and teachers and DTE evaluated the short-term teaching effect. The DTE was the test at the end of the rotation, and it contained a history test and a test of basic clinical skills. The history test script was randomly selected from the other three scripts, and it was different from the training script. The checklist for the assessment of history-taking skills (a maximum of 15 points) is presented in Supplementary File 1. Only one introductory clinical operational skill could be randomly selected for assessment due to limitations. of time. Both groups were assessed with the checklist items (a maximum of 100 points) displayed in Supplementary Folder 2 (comprising four sheets). All participants were assessed one by one in random order by a blinded examiner, and all scoring criteria standards were formulated following CMLE 2020. The student subjective questionnaire was designed based on a 5-point Likert scale and included five items (5 = agree, 1 = disagree). Questionnaire items were chosen based on a previous report and our teaching experience . Each resident anonymously rated the quality of teaching received using the post-rotation questionnaire. Each student’s clinical teacher will subjectively rate their daily clinical performance after the immediate rotation, and the evaluation involves the following three aspects: theoretical knowledge, self-directed learning ability, and doctor-patient communication skills.
The long-term teaching effect was assessed by the clinical skills performance of the CMLE for the first time, which was considered a 9-month retention test used to assess the skills of each individual. Aggregate test scores and pass rate were used as evaluation indicators.
We have compiled the total score for each test. When a normal distribution was present, the results generated by each of the two groups were compared using an independent sample t-test and reported as the mean ± SD. Otherwise, non-parametric test methods, such as the Mann-Whitney-Wilcoxon test, were used, and the result could be reported as the median (lower quartile, upper quartile). The chi-square test was used to analyze the difference in rates between the two groups. All statistical analyzes were performed using SPSS software (version 22.0). P values less than 0.05 were considered significant. Cohen’s effect size sd was calculated to identify the magnitude of any difference between the two groups. The practical effect size proposed by Cohen’s sd value was considered to be small (0.8, .