Child standardized patients in pediatric OSCEs: a feasibility study for otoscope examination among undergraduate students in Rwanda

Abstract

Background

Otoscope examinations are a fundamental skill in pediatric care, crucial for diagnosing and managing ear conditions such as otitis media. Traditional training methods for pediatric otoscopic examination often rely on adult standardized patients (SPs) or simulated models, which may not be adequate for pediatric examinations.

Objectives

This study evaluates the feasibility and effectiveness of use of children as SPs in Objective Structured Clinical Examinations (OSCEs) to assess medical students’ competency in pediatric otoscopy.

Methods

This descriptive cross-sectional study was conducted at the University of Global Health Equity (UGHE), Rwanda during the final exit examinations. This study included 30 final-year medical students, and six child SPs aged 5–8 years, along with their guardians. Quantitative data were collected using structured questionnaires on students perceived self-efficacy and performance. Qualitative data were obtained through focus group discussions with guardians and child SPs.

Results

The mean (standard deviation) performance of students at the otoscope examination station was 81.67 (5.7) %, with a significant positive correlation between perceived self-efficacy and actual performance (r = 0.493, p = 0.006). The mean performance at the OSCE station was slightly higher than perceived students’ self-efficacy, (72.5 (6.8) vs. 81.67%. p < 0.001). Students reported high levels of satisfaction with the use of child SPs, with 83.3% recommending their use in pediatric OSCEs. Guardians and child SPs also expressed overall satisfaction, though concerns were noted regarding students’ levels of confidence. and communication skills.

Conclusion

Incorporating children as SPs in pediatric OSCEs enhances the realism and educational value of otoscope training with positive correlation between perceived self-efficacy and actual performance.

Introduction

The accuracy and thoroughness of otoscope examinations are critical for diagnosing and managing pediatric ear conditions. Otoscope examinations are a fundamental clinical skill that medical students must master, particularly in the context of pediatric care where ear pathologies are common [1]. Pediatric ear conditions, such as otitis media, external otitis, and cerumen impaction, are prevalent and can significantly affect a child’s health and quality of life [2]. Early and accurate diagnosis through otoscope examination is essential for effective treatment and management. Physicians should also be proficient in performing otoscopy and conducting ear examinations during any physical exam. This skill is especially critical in pediatric patients, as otitis media is a common cause of fever, a frequent complaint in this age group [3]. However, traditional training methods, including assessment, which often rely on adult standardized patients or simulated models, may not provide sufficient exposure for evaluation of students regarding pediatric patients [4]. These limitations can potentially compromise the training and assessment of competency of medical students when they encounter real pediatric patients in clinical practice.

In our medical school, the pediatric and ENT curriculum includes comprehensive teaching of ear examination, clinical reasoning and communication in pediatrics through a combination of training models, supervised clinical examinations of real patients, and simulation-based OSCE sessions during formative assessments. Students have the opportunity to practice essential skills, such as ear examinations, in both simulated and real-patient settings under supervision. Although we were confident that otoscopy skills were being adequately taught during the pediatric and ENT clerkships, we wanted to assess students’ ability to integrate and apply their knowledge and skills to patients similar to those they would encounter in clinical practice. Additionally, we sought to evaluate the feasibility and effectiveness of using pediatric standardized patients (SPs) to assess the approach to a patient presenting with ear pain.

Medical education has increasingly recognized the importance of standardized patients (SPs) in clinical skills training [5]. SPs offer a realistic and controlled environment for students to practice and refine their clinical skills. Studies have shown that SPs enhance clinical skills, diagnostic accuracy, and communication abilities [6]. However, the use of adult SPs may not adequately prepare students for pediatric examinations due to anatomical and behavioral differences between adults and children.

Incorporating children as SPs in medical education presents unique challenges. Ensuring the safety, comfort, and ethical treatment of child SPs is paramount [7, 8]. Additionally, training children to consistently portray clinical scenarios requires specialized approaches [8]. Despite these challenges, the potential benefits of using child SPs include more realistic training experiences for students, improved diagnostic accuracy, and better preparation for real-world clinical practice. Utilizing children as SPs can bridge the gap in pediatric clinical training. By practicing on child SPs, students can gain experience in handling pediatric patients, recognizing pediatric-specific symptoms and signs, and communicating effectively with both children and their guardians [9]. This hands-on experience is invaluable for building confidence and competence in pediatric care [10].

The efficacy of SPs in medical education has been well studied. It has been demonstrated that SPs improve clinical skills and diagnostic accuracy of students [2, 11] When trained well, SPs were found to improve the exams’ reliability and validity [4]. Using SPs has become an effective method for evaluating clinical competence in Objective Structured Clinical Examinations (OSCE) [12]. Otoscopic skills assessment of students on manikins [7] and video otoscopes [8] has been studied. However, research specifically focusing on the use of child SPs in otoscope examination training is limited. This study aims to fill this gap by evaluating the feasibility and effectiveness of using pediatric SPs in OSCEs for otoscope examination.

The feasibility measured in this study primarily focused on multiple dimensions:

1. Technical Feasibility - Evaluating whether children could effectively serve as standardized patients for otoscopic examinations, including their ability to simulate conditions reliably and tolerate the procedure without discomfort.

2. Logistical Feasibility - Assessing the practicality of recruiting and training children and their guardians, ensuring standardization across cases, and managing their participation in a controlled assessment environment.

3. Educational Feasibility - Determining whether using children as standardized patients provides meaningful, realistic training for students and aligns with the educational goals of preparing them for pediatric practice.

Hence, we evaluated the competency of final-year medical students in performing otoscopy using a handheld otoscope, the reliability of children’s performance as SPs and their guardian’s satisfaction level with their children participating in OSCEs as a child SP. We also compared students’ self-assessments to their actual performance, as self-assessment data can provide educators with valuable insights into students’ self-perceptions, revealing trends and guiding feedback strategies. By exploring these aspects, the study seeks to contribute to the development of more effective pediatric clinical education strategies, ultimately enhancing the quality of care provided to pediatric patients.

Methods

Study design and settings

This was descriptive cross-sectional study and involved quantitative and qualitative methods conducted at the University of Global health equity (UGHE) campus during the final MBBS qualifying exit OSCE examinations. The exit qualifying clinical exam is designed as an integrative clinical assessment, combining OSCE stations that evaluate skills across multiple specialties. This otoscopic examination station was structured to assess competencies relevant to both Pediatrics and ENT, reflecting the crossover skills required in real-world clinical practice when managing pediatric patients with ear-related conditions. This dual focus highlights the importance of interdisciplinary knowledge and its application in clinical scenarios. This exam included a station where students were presented with a clinical vignette describing a child with ear pain and fever and were instructed to perform the most relevant part of the physical exam. Students were evaluated not only for their technical ability but also for their communication skills, attitude, and behavior, providing a comprehensive assessment of their clinical competencies.

Study participants

This study included all (thirty) final-year medical students, the guardians and children who participated as SP in the final qualifying exit examination. All students, guardians and children who participated in the OSCE were eligible and enrolled in the study after providing consent.

Sample size

The sample size for the quantitative analysis consisted of all 30 medical students who participated in the pediatric OSCE component of the exit examinations. For the qualitative analysis, the sample included five SP children and their respective guardians who participated in the OSCE exams. These participants were selected for focus group discussions (FGDs) to gather in-depth insights into their experiences and perspectives.

Participants recruitment and data collection: Participants were recruited, and data were collected in a two-phase approach:

Recruitment of Guardians and SP Children. Prior to the examination date, guardians of children aged five to eight years were approached with a detailed explanation of the study’s purpose, procedure and potential risks and benefits. Guardians who consented to participate allowed their children to serve as SPs during the pediatric OSCE. These SPs and their guardians were then invited to participate in FGDs following the exam.

Standardized patients (SPs), consisting of children aged five to eight years, and their guardians were recruited from the community surrounding the university campus. These SPs and their guardians were brought to the campus for a screening and training session prior to the examination day.

During the session, two pediatricians and one General Practitioner, including two who are fluent in the local language, provided the children and their guardians with a detailed explanation of their roles as SPs in the OSCE and emphasized their right to stop the exam at any point. The pediatricians then performed an otoscopic examination on each child’s ears to ensure their suitability for the role. For each child, each ear was examined one after the other following standard techniques. They were also taught how to express themselves if there was any discomfort by role play. Of the 6 SPs examined, 5 had normal otoscopic findings and were selected to participate in the exam. One child was found to have otitis media with effusion and consequently was not selected for the examination. This child was referred to the local clinic for further evaluation and treatment.

For guardians, training included how to respond to student inquiries, mirroring typical parental concerns and emotional responses that students would encounter in real scenarios. This helped create a realistic, emotionally resonant interaction, aligning the assessment closely with real-world pediatric care.

Recruitment of Medical Students: Following the completion of the OSCE, all 30 medical students were approached and received a comprehensive explanation of the study and were invited to participate in the study. Each student provided informed consent before participating. The students were then asked to complete a structured questionnaire designed to assess their satisfaction with the examination process and their perceived self-efficacy in the Pediatric otoscopy in the context of interacting with child SPs.

Quantitative method: structured questionnaires were distributed to the students after they completed their final examinations. The questionnaire assessed their satisfaction level with the use of child SPs in the OSCE on a five-point Likert scale. It also assed their perceived self-efficacy, defined as one`s expectations of his/her ability to perform various tasks successfully and achieve desire goals [13]. This was assessed by asking about their confidence and perceived ability to manage pediatric patients and also rated on a five-point Likert scale with options from “Very Low” to “Very High”. And finally, the students’ performances in the otoscope station of the OSCE were assessed using a standardized checklist. This checklist evaluated technical ability, communication skills, confidence, and diagnostic accuracy. Each of these aspects was rated on a five-point Likert scale (Very Good, Good, Average/Fair, Poor, Very Poor). The performance data were extracted anonymously, de-identified, and compiled for analysis.

Qualitative method: The qualitative component of the study involved focus group discussions (FGDs) with the guardians and children SPs who participated in the OSCE. Separate FGDs were conducted with the guardians and the SP children. The discussions with the guardians focused on their satisfaction with the examination process and their assessment of the medical students’ performance in interacting with their children. The children’s FGDs were designed to be age-appropriate and aimed at understanding their comfort levels and experiences during the OSCE. The session was audio-recorded and transcribed verbatim afterward. The transcripts were analyzed thematically to identify recurring themes related to satisfaction, the perceived quality of student performance, and any challenges encountered during the examination process.

Data analysis

For the quantitative part of the study, data were entered and analyzed using SPSS version 29. The demographics (age) was summarized using mean with standard deviation. A frequency Table was used to summarize the students’ responses on perceived self-efficacy, and recommendation on using children for SP. Furthermore, the Likert Scale response was graded from 5 to 1 as follows [Strongly agree = 5; Agree = 4; Neutral = 3; Disagree = 2, Strongly disagree = 1] and was used to derive the mean of responses for students’ self-efficacy, while the extracted examination raw score converted to percent was to for the actual students’ performance. We compared the scores from the OSCE station with students’ self-efficacy using Pair-T test and explored the association between the two variables using Pearson correlation test.

For the qualitative data analysis, the focus group discussions with guardians and child SP were recorded and transcribed, then coded to identify recurrent theme and patterns. Key themes related to satisfaction, comfort, understanding and preparation for the examination were extracted and reported.

Results

General characteristics: students

The mean age group of the students was 23.7 (SD 0.8) years with a minimum of 22, a maximum of 25 years and 63.3% were females.

Students’ evaluation of the station on the ear examinations of a child (standardized patient).

Of the 30 students that took part in this study, 29 (96.7%) reported that they thought they performed well at the station and were all able to visualize the auditory canal and ear drum. Twenty-six (86.7%) were able to identify whether the ear findings were normal or abnormal. Also, all the students agreed that the children used as standardized patients were very cooperative and 80.0% agreed they are ideal for the station while 83.3% would recommend using children as SP for pediatric examinations (Table 1).

Table 1.

Students evaluation of their performance and children used as standardized patient at ear objective structure clinical examination station

Variable	Question	Responses n = 30 [Agreed and strongly agreed]	%
Students’ self-efficacy of their performance	I performed well at the station on the examination of the child’s ear	29	96.7
Examination of ear of the children	The child made the otoscopic examination easier by allowing me to position the ear well	23	76.7
	During the otoscopic examination, I was able to visualize the auditory canal and ear drum	30	100
	During the otoscopic examination, I was able to clearly identify any pathology or normal ear findings	26	86.7
Cooperativeness of the children	The children were cooperative during the ear examination	30	100
Recommendation on using children as standardized patient	I think children are ideal for ear examination OSCE station	24	80.0
	I think children should be used as standardized patients for Pediatric OSCEs	25	83.3

SP-Standardized patient; OSCE: Objective structure clinical examination

Students’ self-efficacy and performance at the OSCE station

The mean (standard deviation) students perceived self-efficacy (one`s expectations of his ability to perform various tasks successfully) was 72.5 (6.8) %, with a minimum of 52.0% and a maximum of 80.0%, while the mean performance at the station was 81.67 (5.7)% with a minimum of 72.5% and a maximum of 92.5% The mean performance (examinations) at the OSCE station was slightly higher than perceived students’ self-efficacy, (mean diff = 8.717, p < 0.001). There was good positive correlation between students’ self-efficacy and actual performance (Pearson correlation coefficient, r = 0.493, p = 0.006).

Students’ perception on using children as standardized children

Of the 30 students, 11 gave additional comments and were mostly positive, with 8 of the 11 agreeing that having children as SP is either good or great and that they were very cooperative. A candidate suggested a need for adequate training of the child SP as the child SP could not indicate which the ear was for examination. At the same time, another student recommended frequent changes of the children.

Themes identified

Overall satisfaction

All parents and children expressed satisfaction with their experience. Parents appreciated the opportunity for their children to participate, viewing it as beneficial. They believe their participation in this has contributed to the development of the futures doctors to be. Children generally found the examination experience positive and likened it to a normal or enjoyable activity.

Confidence and Performance of Medical Students:

Parents’ Perspective: While parents were generally impressed by the students’ performance, they identified a lack of confidence in some students, despite their evident knowledge and skills. Parents suggested that building more confidence could improve the students’ performance in future exams.

Parent No 3 “I was impressed by their knowledge, but I think they could perform even better if they believed in themselves more.”

Children’s Perspective: The children did not express concerns about the students’ performance but did note that in some instances, explanations were not provided before the examination.

Child No 2 “The check-up was fine, but sometimes they didn’t tell me what they were going to do before they did it.”

Communication:

Parents’ Perspective: Parents were pleased with the way students handled the children, but there were slight concerns about a need for better communication and consistency in practices.

Parent No 1 “Overall, the examination was good, but sometimes it felt like there wasn’t a clear explanation of what the students were doing.”

Children’s Perspective: Some children noted that not all students provided clear explanations before proceeding with the examination. While most children felt reassured, one child did experience some discomfort.

Suggestions for Improvement:

Parents: Focus on building student confidence to improve their interaction and examination process.

Children: Emphasized that students should not be afraid and should ensure clear communication before performing any procedures.

Statement:

The qualitative analysis of the interviews conducted with parents and children who participated in an otoscopic examination conducted by medical students during an OSCE of a final year medical student exam reveals overall satisfaction with the experience. Parents appreciated the practical experience, recognizing the importance of such training for future healthcare professionals. However, a recurrent theme was the students’ need for greater confidence during the exams, as noted by both parents and children. While communication was generally adequate, with most students explaining the procedures, there were isolated instances where this was not consistent. Moving forward, teaching should emphasize repeated supervised practice of otoscopy until the students can gain the necessary confidence and should emphasize the importance of teaching communication skills before and during otoscopy in children. The findings also highlighted that some of the students need further practice so that they can gain more confidence and need to be thought about the importance of communication.

Also, worthy of note is that none of the children who took part in this study experienced any form of injury during the examination.

Discussion

Standardized patients are important parts of clinical teaching and examination for undergraduate medical training but there is limited data on the use of children as standardized patients, especially in sub-Saharan Africa. The findings from this study highlight the potential benefits and challenges associated with having children’s patients (SPs) in Objective Structured Clinical Examinations (OSCEs). Our study shows that there is a correlation between the competency of medical students in performing otoscopy in children SPs and their perceived self-efficacy. This is particularly important in pediatric care, where the anatomical and behavioral differences between children and adults require specialized training. This observation may not be unexpected as the hands-on students’ experience with children during their training allowed them to develop the necessary skills to handle pediatric patients more effectively, improving diagnostic accuracy and confidence.

Among challenges identified in the Pediatric SPs are the consistency and reliability of child SPs in portraying clinical scenarios. While adult SPs are typically well-trained to simulate medical conditions consistently, the variability in children’s behavior and responses can introduce inconsistencies in the examination process. However, the study’s results indicate that with proper training and support, child SPs can reliably simulate pediatric conditions, offering a valuable educational tool for training and assessing the medical students. The observation of reliability of child SPs in this study for otoscopic examination supported role of OSCE in pediatric training of undergraduate students as observed by Paul and colleagues in USA [14].

The study also explored the satisfaction levels of students, child SPs, and their guardians. Overall, students reported high levels of satisfaction with the use of child SPs, noting that the experience better prepared them for real-world clinical practice. Guardians and child SPs also expressed positive feedback, though a few concerns were raised regarding the potential discomfort experienced by the children. Ensuring the safety and comfort of child SPs is paramount, and the study’s methodology included strategies such as thorough explanations, role-playing, and regular breaks to mitigate these risks.

The ethical implications of using children as SPs were carefully considered in this study. The safety, comfort, and psychological well-being of the child SPs were prioritized, with measures in place to address any potential discomfort or anxiety. While there are inherent challenges in involving children in medical education, the study suggests that these can be effectively managed with appropriate protocols and support.

This study underscores the potential benefits and challenges of incorporating children as standardized patients (SPs) in clinical training and OSCEs for medical students, particularly in the context of pediatric otoscopy. Our findings suggest that the use of child SPs enhances medical students’ skills, confidence, and preparedness for real-world pediatric care, demonstrating a positive correlation between hands-on experience and perceived self-efficacy. Despite concerns about variability in children’s behavior and the potential discomfort for child SPs, with adequate training, support, and ethical safeguards, child SPs can reliably simulate clinical scenarios. This contributes significantly to the effectiveness of pediatric training, enriching the overall educational experience while ensuring the safety and well-being of the children involved.

Limitations and future research

Despite the positive outcomes, the study has some limitations. The sample size was relatively small, and the findings may not be generalizable to all medical education settings in sub-Saharan Africa. Additionally, the study primarily focused on the feasibility and initial outcomes of using child SPs, leaving room for further research to explore long-term impacts on clinical competency and patient care. Future research should consider larger, more diverse cohorts and explore the integration of child SPs across different clinical skills and specialties. Longitudinal studies could provide insights into how early exposure to pediatric patients through SPs influences the development of clinical skills and confidence in pediatric care over time.

Conclusion

The study demonstrated that incorporating child SPs in OSCE is feasible and can enhance the realism and educational value of pediatric otoscopy training, providing medical students with more accurate and relevant experiences. The children and their guardians are generally positive about their roles as child SPs. With careful planning and ethical considerations, the use of child SPs could play a crucial role in enhancing pediatric clinical education and ultimately improving the quality of care provided to pediatric patients.

Annex I

Probe questions for guardians

Can you describe/tell us the experience of your child’s participation in the exams.

Can you describe/tell us how comfortable you were with the students while they were performing ear examination of child.

Tell us the performance of our students in carrying out ear examinations of your child.

Tell us about any other suggestions you have for us.

Probe questions for Children SPs

Tell us how you feel with your ear being checked?

Did you understand what the medical students were doing during the examination.

How well were things explained to you before and during the session with the student?

How did the medical students talk to you? Did they make you feel at ease?

Did you Find it easy to act like a patient? What helped you do this well?

What did you enjoy the most about the role of this experience?

What did you like/dislike or find difficult about being a standardized patient?

Tell us what you want our students to do more or less?

Author contributions

BE conceptualized this work, and was involved in the study design, literature search, data curation, data analysis, draft and final version of this manuscript. IO was involved in literature review, study design, data curation, data analysis, draft and final version of this manuscript. JA was involved in the data curation, data analysis, draft and final version of this manuscript. AB and NM were involved in the study design, data curation, data analysis and supervised the conduct of the study. All the authors reviewed and approved the final version of this manuscript.

Funding

There was no external funding for this study.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Ethical clearance was obtained. Each study participant was informed about the purpose and objective of the study. Written informed consent was obtained prior to data collection. Privacy and confidentiality were adhered too, as the data collection was anonymous. Informed consent was obtained from the medical students and from the children’s guardians (to have their children participate as SP and for them to participate in the study). We also obtained assent from the children SP. We ensured the safety and comfort of child SPs throughout the study, with a pediatrician on-site during the examination to address any potential medical or psychological concern. The perspective on safety for both the children and the examiners was critical in the study. For the children, safety considerations included ensuring that the otoscopic examination was non-invasive and performed by candidates under direct faculty supervision. Training for the standardized patients included guidance on signaling any discomfort, while guardians were present to oversee the process and ensure the children’s well-being. The examinees’ safety measures (students) involved proper training in otoscopic technique to avoid any risk of harm to themselves, such as handling the equipment appropriately to prevent injury during their pediatric clerkships. Additionally, with faculty oversight, the controlled environment of the OSCE minimized potential risks to both participants and ensured a safe learning and assessment experience. Data collected from the medical student, guardians, child SP and examiners were de-identified and stored in an anonymized manner to protect the confidentiality of the participants. Data was stored securely in password protected files and access to data was limited to the researchers. UGHE IRB approved this study with approval number: UGHE-IRB/2024/341-EXE. The research was conducted following standards in accordance with the Declaration of Helsinki. All methods were carried out in accordance with relevant guidelines and regulations.

Consent for publication

Written informed consent for publication of their response was obtained from participants of this study. A copy of the consent form is available for review by the Editor of this journal.

Competing interests

The authors declare no competing interests.