The mandatory shift to online medical education expanded the scope of computer-mediated instruction, forcing medical educators to re-examine existing training methods for practical skills traditionally reserved for the CSL and bedside . This shift created the unprecedented opportunity to assess online learning, blended learning, and face-to-face approaches to clinical training allowing the merits of all three approaches to be vetted. We found that our 2021 students were competent in the affective, cognitive, and psychomotor domains of clinical skills, which required different degrees of transfer for learning to occur. Furthermore, the integrated online and blended platforms produced superior results to the traditional teaching approaches in some respects.
The flipped classroom (FC), a type of blended learning, focuses on asynchronous, independent, student-centered, self-paced learning of foundational concepts in preparation for in-class application with the teacher [13, 45, 46]. According to the systematic review by Chen et al. (2017), there are inconsistencies regarding its effectiveness, especially in undergraduate medical education . Our study, however, focused on accomplishing the educational purpose by blending online and face-to-face elements using various methods, including online synchronicity, virtual and in-person group work, and active learning with tutor-driven and student-driven engagement . Though blended learning has received positive responses as an effective active learning strategy for theoretical knowledge, it has had a minimal role in clinical skills [2, 33, 38, 48]. Students in our study competently demonstrated psychomotor skills they had never previously attempted. The remote online teaching programme provided knowledge through asynchronous online self-directed pre-learning material, synchronous online lectures, interactive practical zoom sessions, video demonstrations, and quizzes. Learning hands-on skills like the obstetric examination and pap smear procedure on an online platform required degrees of far transfer for students to perform the skills competently. Competent execution of these skills in the CSL was interesting since skills requiring far transfer are more difficult to perform [20, 22]. Further, similar to the findings by George et al. , our study highlights the positive impact of blended learning as Group A1 students’ performance was significantly better compared to the 2019 face-to-face students (Cohort B). The latter performed the same skill in a traditional summative onsite OSCE. Although OSCEs are considered less stressful than other examinations , the summative assessment may have impeded the 2019 students’ performance due to examination nervousness and anxiety. The 2021 students’ assessment was formative; however, the procedures assessed were technically more challenging for these students taught online due to the lack of opportunity and equipment required for self-directed practice. Perhaps the instructional teaching design, which was deliberately tailored to the online platform by employing novel home simulations, may have contributed to the higher performance in the blended group. Offiah et al.  and Anderson & Warren  found that simulation-based training is a successful online and onsite instructional technique that enhances learning. The psychomotor results achieved by Group A1 support Lala et al. , who described the blended learning teaching model as improving bedside training and essential clinical skills training. Aspects of online learning are possibly superior to traditional learning and bridge the gap between the textbook and the “hands-on” application of learned skills [21, 51].
Our study showed that using an online platform, with quality adaptations to teaching on par with traditional methods and learning process integration, could effectively train students for performance-based clinical skills requiring far transfer.
The 2021 learners (Cohort A) demonstrated competence in the affective domain. Although the OSCE’s clinical case was changed, the elements in the initial teaching context were nearly identical to the exam setting, facilitating the evaluation of near transfer. This increased the likelihood that learners would perceive the two scenarios as comparable, resulting in improved transfer .
While online proctoring can be challenging , our study found that the directly assessed history-taking scenario was dynamic, requiring students to interact and actively demonstrate process skills and develop interpersonal relationships. This included showing empathy, emotions, and an existing knowledge base while gathering information from the simulated patient and clinically reasoning through the process.
Comparatively, Cohort A outperformed Cohort B, with the e-learning group (A2) performing better than the face-to-face group (Cohort B) in the history-taking skill. A possible reason is that virtual simulation-based training using the Zoom online platform enabled interactive small group teaching that facilitated the effective transfer of communication skills [6, 53]. Unlike onsite teaching, the continuous active learning strategies via Zoom’s online chats, polls, and breakout rooms ensured the engagement of all students during teaching sessions. The blended learners (A1) performed the best, despite receiving the same online instruction as Group A2. Shahrvini et al.  reported that students could perceive online learning as isolated due to a lack of connection to their colleagues and the institution, resulting in increased anxiety. The in-person interaction of the blended group (Group A1) with tutors at the formative OSCE may have reduced their anxiety, resulting in their higher scores. Our study thereby confirmed suggestions by Prober & Khan  that interactive and collaborative activities that reinforce the constructivist model could exceed the expectations of the learner using the online platform .
In the traditional OSCE, the emphasis of the psychomotor domain was the technical demonstration of a physical examination or procedural skill. A clinical reasoning question was asked at the end of these performance-based skills and comprised approximately 15% of the overall examination score. For the online tm-OSCE, intellectual skills such as establishing a knowledge base, problem-solving, and critical thinking were examined as a viva voce in two five-minute scenarios and comprised 100% of the scores. Despite this novel component, students displayed adequate clinical knowledge retention when reasoning through procedural and examination-related cases. Students explained, defined, and rationalised the purpose of these skills, demonstrating near transfer of abilities since the assessment setting was similar to the learning environment .
Further analysis of the assessment scores revealed that the blended group, who practiced examination and procedural skills onsite, outperformed the e-learning group. This finding supports Turk et al. , who reported that combining online teaching and onsite performance may be preferable to online teaching alone.
Student characteristics, learning design, and onsite environmental conditions are also aspects to consider for the performance gap between the two groups . Since the blended student group had volunteered for the onsite session, they may be more self-motivated. The formative OSCE was also preparation for the summative examination implying spaced learning . The structure of the formative assessment allowed students to have one-on-one tutor interaction, where techniques were corrected and questions answered. Furthermore, the onsite practice allowed students to construct the applied skills on their existing knowledge, which is crucial in developing competence [18, 57, 58].
Despite the differences between the subgroups, Cohort A’s overall performance meant that most students could have a meaningful discussion with the examiner, demonstrating clinical reasoning and knowledge transfer . Compared to the pre-pandemic onsite OSCE, the online viva voce examined a more significant proportion of the cognitive domain. Knowledge of clinical skills, emphasised in Step 4 of the adaptations as “Comprehension”, is essential for proficient performance . According to Remmen et al. (2001), written tests are feasible alternatives to demonstration-based testing and can predict the student’s performance in the OSCE. Early exposure to understanding concepts coupled with CSL training and assessments may lead to better diagnostic reasoning, information retention, and student preparation for hospital rotations [16, 60]. Since online cognitive skills training went beyond the face-to-face scope, combining an e-learning platform with traditional teaching and assessment methods can potentially produce better outcomes .
Our study showed that medical students taught clinical skills on an online platform can effectively retain knowledge and transfer affective, cognitive, and psychomotor skills competently, bridging the theory-practice gap in three domains of clinical skills. Using a variety of blended teaching delivery approaches that extend beyond the scope of the FC and arranging immediate application opportunities, with support from clinical educators, could explain the higher-level transfer of assessed skills . The improved transfer to “hands-on” practice petitions a revised blended-teaching strategy designed at the planning stage of the academic curriculum. The advantage of incorporating the tutor-driven blended adaptations and the student-driven FC is that it efficiently promotes a high-quality application of skills. Besides the academic advantages, online learning also allows students to build their skills and confidence before interacting with simulated or actual patients and other medical professionals . Finally, in resource-constrained training contexts, the documented benefits of the online platform regarding time management, flexibility, and cost-effectiveness [38, 54, 56] could mean that more students can be included and trained.