Research papers

Bene®ting from clinical experience: the in¯uence

of learning style and clinical experience on performance
in an undergraduate objective structured clinical examination

Iain G Martin,1 Patsy Stark2 & Brian Jolly3

Objective To assess the relationship between clinical clinical experience. A signi®cant relationship between
experience, learning style and performance in an clinical experience and organized deep-learning styles
objective structured clinical examination (OSCE) in suggests that knowledge gained from clinical experience
medical students at the end of their ®rst clinical year. is related to learning style.
Design Prospective study of undergraduate students Conclusions The relationship between clinical ex-
taking an OSCE examination at the end of their ®rst perience and student performance is complex.
clinical year. Well-organized and strategic learning styles appear to
Subjects 194 undergraduate medical students (95 in¯uence the bene®ts of increased clinical exposure.
male). Further work is required to elucidate the most bene®-
cial aspects of clinical teaching.
Main Outcome Measures Performance in the OSCE
examination, the Entwhistle Learning Style Inventory1 Keywords Undergraduate medical education, *meth-
and a composite self-reported score of clinical activity ods; medical students, *psychology; *learning; clinical
during the students ®rst clinical year. medicine, *education; educational measurement,
methods; prospective studies.
Results Performance in the OSCE examination was
related to well-organized study methods but not to Medical Education 2000;34:530±534

clinical experience of students and their subsequent

Introduction
performance has always been recognized as complex. It
Medical training, which until recently has been based is important that we understand how students bene®t
upon the apprentice/master model, is in a period of from clinical experience and what types of experience
considerable change. The GMC's document, Tomor- are most bene®cial.
row's Doctors2 is leading to radical change within the The need to accurately assess a student's clinical
undergraduate medical curriculum. The traditionally abilities is of great importance if we are to be certain
overburdened curriculum is being pared down to that that the new curricula are meeting our objectives. Not
which is considered core, with as much as 30% of the only do we need to ensure that we produce competent
course being devoted to special study modules. Whilst graduates, but that they will continue to learn from
these new curricula offer many opportunities, the ed- experience throughout their professional careers and
ucators of the next generation of doctors must produce embody the characteristics of SchoÈn's Re¯ective Practi-
graduates skilled in clinical medicine. Traditionally, tioner.3 The assessment methods that we choose for our
clinical competence has been developed from periods of students must encourage both the development of the
experience on wards, however, the relationship between clinical skills we require and reward the type of deep
and meaningful learning we value. To date, there
appears to be no clear relationship between clinical
1
Senior Lecturer in Surgery, Undergraduate Surgical Education experience and either performance in an OSCE exam-
Co-ordinator, 2Director, Clinical Skills Centre, 3Director, Medical ination4 or surgery exit examinations.5 McManus6 has
Education Unit, Division of Surgery & Department of Medical Edu- recently demonstrated a lack of correlation between the
cation, Leeds University Medical School, Leeds, UK
results of traditional ®nal year examinations and clinical
Correspondence: Iain G Martin, Academic Department of Surgery, The
General In®rmary at Leeds, Great George Street, Leeds LS1 3EX, experience and has suggested that alternative methods
UK of assessment should be explored.

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Clinical experience and performance in an undergraduate OSCE · I G Martin et al. 531

In 1995, we introduced an OSCE examination at the

Clinical experience
end of the ®rst clinical year (year 3), both to emphasize
to students the importance of clinical skills and to assess The students were asked to report, in a questionnaire,
their acquisition of these fundamental tools of their three important aspects of their clinical experience dur-
future career. The examination is run jointly by the ing the year. Firstly the total number of patients clerked,
Divisions of Medicine and Surgery and although not a secondly the number of outpatient clinics attended and
degree level examination, failure in the examination thirdly the number of emergency `takes' the student
may result in failure to progress to year 4 of the course. attended. For each of the parameters, the students were
The examination consists of 24 stations assessing a given options of various levels of activity. For the num-
broad range of clinical skills ± history taking, bers of patients clerked this varied from 5 or less through
examination skills, communication skills, practical to more than 40, for numbers of outpatients attended this
procedures (e.g. venepuncture and basic life support, varied from less than 5 to more than 20 and for number of
electrocardiographic tracing's and patient observation emergency takes, from none to more than 10. The an-
charts). Whilst recognizing the limitation of such an swers were grouped to give a numerical score and the
examination in that it breaks down the clinical process total amount of clinical experience was taken as a com-
into a series of discrete steps, the OSCE has been bined score for the three areas of clinical activity.
shown to be a representative, fair assessment of stu-
dent's clinical abilities.7 It should reward students who
Statistical analysis
use their clinical exposure wisely and should not
encourage surface learning of rote fact. The aim of this Statistical analysis was performed using SPSS 7á5 for
study was to assess the relationship between the stu- Windows. Correlation coef®cients between OSCE
dent's learning style, clinical experience and their per- scores or clinical experience and the learning style
formance in the examination. inventory data were reported both `raw' and adjusted
for attenuation.10
Subjects and methods
Results
The current Leeds undergraduate curriculum has two
preclinical years followed by three predominantly clin-
OSCE
ical years. The third year course, run jointly by the
Divisions of Medicine and Surgery, aims to teach the The mean mark for the OSCE examination was 76%
students key clinical skills and, coupled with a course in (range 56±92%). The reliability coef®cient (Cronbach's
laboratory and scienti®c medicine, is designed to give alpha) for the OSCE examination was 0á702. For the
the student a fundamental grasp of the clinical practice history, examination, data interpretation and practical
of medicine. The clinical component comprises skills subsections of the OSCE examination the reli-
attachments to four clinical ®rms, with one day a week ability coef®cients were 0á519, 0á593, 0á321 and 0á432,
devoted to formal clinical skills teaching run jointly by respectively, largely re¯ecting the smaller numbers of
the divisions of medicine and surgery. stations in each subsection.
In the academic session 1997±98, 194 students were
taught and examined. As described above, the exami-
Learning style
nation took the form of a 24 station OSCE.
To assess the student's learning style, the learning Of the 194 students, 150 (77%) returned a completed
style inventory of Entwhistle1 was used. This 30 ques- form. Reliability coef®cients for the achieving scale, the
tion inventory, which has been used in the evaluation of reproducing scale and the meaning scale were 0á53,
medical students previously,8,9 has three principle and 0á49 and 0á49, respectively.
four supplementary components: an achieving scale, a
reproducing scale (surface learning) and a meaning
Clinical experience
scale (deep learning) being the ®rst three, and com-
prehension learning, operation learning, versatile There was substantial variation in the reported clinical
approach and learning pathologies the subsequent four experience: the mean clinical activity score was 11á2, with
components. Entwhistle also described a composite a range of 5±16. The numbers of patients clerked varied
score described as an overall predictor of academic from between 6 and 10 to 30±40, the number of outpa-
success. Students were asked to complete this inventory tient clinics between 0 and 5 and more than 20 and the
within 1 week of the examination. number of emergency takes between 0 and more than 10.

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532 Clinical experience and performance in an undergraduate OSCE · I G Martin et al.

Table 1 Correlation between learning

Learning style component Correlation with clinical experience style and composite clinical experience
score
Achieving ± well-organized study methods, r = 0á189 (adjusted 0á317)
competitiveness and hope for success P = 0á043
Reproducing ± surface approach to learning, r = ) 0á112 (adjusted ) 0á188)
extrinsic motivation and syllabus boundness P = 0á231
Meaning ± deep approaches to learning, r = 0á317 (adjusted 0á532)
intrinsic and academic motivation P = 0á001
Comprehension r = 0á063 (adjusted ) 0á106)
P = 0á5
Operation r = 0á030 (adjusted 0á055)
P = 0á75
Versatile r = 0á321 (adjusted 0á538)
P < 0á001
Pathological r = ) 0á144 (adjusted ) 0á204)
P = 0á122
Overall Success r = 0á345 (adjusted 0á578)
P < 0á001

Learning style and performance Table 2 Differences in learning style and OSCE performance
in the OSCE examination between female and male students (+ve difference ! female
higher score)
The achieving style was associated with performance in
the OSCE examination (r ˆ 0á336 (adjusted 0á563), Mean difference
P < 0á001). There was a negative relationship between Characteristic in parameter 2 tailed signi®cance
the reproducing style and OSCE performance which
did not reach statistical signi®cance (r ˆ ± 0á11 (ad- Learning style
justed ± 0á18), P ˆ 0á18) and a weak non-signi®cant Achieving 0á469 of 24 0á4
positive association for the meaning style (r ˆ 0á12 Reproducing ± 0á655 of 24 0á256
(adjusted 0á2), P ˆ 0á14). When the individual compo- Meaning ± 0á261 of 24 0á635
Comprehension 0á727 of 24 0á128
nents of the OSCE examination were analysed, the only Operation ± 0á324 of 24 0á475
correlation between learning style and performance not Versatile ± 0á752 of 48 0á398
seen with the overall OSCE result was a signi®cant Pathological 0á238 of 48 0á802
association between data interpretation and the mean- Overall ± 0á521 of 120 0á737
ing style (r ˆ 0á168 (adjusted 0á212), P ˆ 0á04). OSCE
History 5á37 of 140 0á001
Data 1á9 of 120 0á348
Clinical experience and performance in the OSCE Examination 3á12 of 140 0á023
Skills 0á09 of 60 0á920
There was no association between clinical experience Total (%) 2á19 0á01
and performance in the OSCE (r ˆ 0á024, P ˆ 0á776).
No association could be found with any of the OSCE
components and any aspect of clinical experience signi®cantly higher levels of clinical exposure during
their ®rst clinical year.

Learning style and clinical experience

The in¯uence of the student's gender
There were strong and signi®cant associations between
on learning style and examination performance
learning style and clinical experience (Table 1). The
students showing learning styles associated with deep, Of the 194 students, 99 were female. There was a trend
strategic and well-organized learning styles reported for the female students to perform better in all aspects

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Clinical experience and performance in an undergraduate OSCE · I G Martin et al. 533

of the OSCE examination (Table 2), most notably the positive learning style and increased clinical experience
history stations, but the absolute differences were small. is both real and important. Although somewhat
The overall mean percentage scores were 77 and 75%, speculative, it appears that students with an achieving
respectively (P ˆ 0á011, independent samples t-test). or meaning orientation both sought out more clinical
There were no differences at all in learning style or cases and perhaps made more of these in terms of
clinical experience reported between the male and their own personal development. Extrapolating
female students. somewhat, it seems that there is a relationship
between the three components of the study, OSCE
performance, learning style and clinical experience,
Discussion
which with a degree of mathematical licence could be
McManus6 has recently shown that performance in the expressed as:
traditional ®nals examination does not re¯ect clinical
experience and that there appeared to be a positive OSCE performance µ Learning style µ Clinical
relationship between strategic learning styles and experience
examination performance. This study was conceived to
look further at this complex relationship in students at An undergraduate medical student should not only be
the beginning of their clinical careers. By examining a skilled in the techniques of clinical medicine and
large number of discrete clinical skills which, it is possess a suitable level of underpinning knowledge, but
thought, are acquired largely by direct clinical experi- also have the ability to continue to develop and learn
ence, the OSCE should provide a broader based throughout their career; in short, to be a `critical
assessment of the student's clinical abilities. Does thinker'.11 The assessments that are used should re¯ect
greater clinical experience result in increased perfor- the sort of graduate we wish to produce. The OSCE is
mance in our OSCE examination? The simple answer is perceived by the students as a valid and fair test of
no. Notably, our results re¯ect closely those of ability and the internal reliability of our OSCE was
McManus6 ± as with the traditional ®nals examination good. Surface learning did not enhance OSCE perfor-
± there is no relationship between the performance in mance, relevant when the evidence is that medical
the OSCE and clinical experience. education has tended to encourage this style of
Good performance in the OSCE examination was learning.8,9 The OSCE examination we currently run at
signi®cantly associated with a learning style character- the end of the ®rst clinical year certainly has resulted in
ized by a desire to achieve and well-organized study a focusing of the students upon the importance of
methods, but, somewhat to our surprise, not with clinical skills, but perhaps still falls short in assessing
learning for meaning nor, negatively, with surface the integrative processes of the `expert' physician;
learning. perhaps an unfair criticism given the context in which
What, then, of clinical experience? It has been the OSCE was being used.
assumed by many that more is always better. The `best' The ®nding that the female students performed
students are often the ones with greater than average better in the OSCE examination, scoring on average
clinical experience ± a fact borne out in this study by the 2á2% higher than their male colleagues, raises some
powerful associations between positive learning styles interesting questions. Much of this difference came
and clinical experience. But, as Samuel Johnson from the history stations and, while it may be that the
pointed out in 1734, `it is incident to physicians, I am female students are more con®dent and ¯uent in
afraid, beyond all other men, to mistake subsequence interviewing patients, we must ensure that the exami-
for consequence' and we must look beyond simple nation techniques used do not produce inadvertent
volume5 to the characteristics of our students and the inequalities.
clinical exposure itself to maximize the educational We need to ensure for the future that students are
bene®ts. We were unable to demonstrate any direct encouraged to develop the positive and bene®cial styles
relationship between clinical experience and student of learning which seem to be of importance in ensuring
performance in the OSCE. However there was a rela- that they gain the most from clinical experience and as
tionship between learning style and clinical experience; educators we need to assess, far more critically than
students whose preferred style was characterized by a previously, exactly which aspects of clinical exposure
greater achieving or meaning orientation reported and teaching are truly of bene®t to our students. How
signi®cantly greater clinical experience. Given the this can be achieved is challenging both to students and
similarity of our results in this area with those of teachers. There is little doubt that feedback from
McManus,6 we believe that this relationship between a teachers to students is important in improving the value

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534 Clinical experience and performance in an undergraduate OSCE · I G Martin et al.

of clinical experience.5 Structure and guidance in the formance of clinical clerks on surgery exit examinations. Am J
way students utilize clinical opportunities must be given Surgery 1996;172:366±72.
as much consideration as the volume of experience 6 McManus IC, Richards P, Winder BC, Sproston KA. Clinical
experience, performance in ®nal examinations, and learning
provided, but more work is required to understand
style in medical students: prospective study. BMJ 1998;316
better the complex relationship between clinical expo-
(7128):345±50.
sure and student development.
7 Newble D, Swanson D. Psychometric characteristics of the
objective structured clinical examination. Med Educ
1988;22:325±34.
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