A workplace-based learning program on clerkship of internal medicine improves medical student’s clinical competence: a retrospective comparative study

Abstract

Background

Clinical competence is a core outcome of undergraduate medical education, yet traditional clerkships often lack structured observation and feedback. This study evaluated the effectiveness of a workplace-based learning program (WBLP) incorporating mini-Clinical Evaluation Exercises (mini-CEX) and Direct Observation of Procedural Skills (DOPS) into an internal medicine clerkship, and its impact on students’ clinical competence and learning satisfaction.

Methods

This retrospective cohort study analyzed outcomes of fourth-year medical students who completed a 9-week internal medicine clerkship at Zhejiang University School of Medicine between September 2024 and May 2025. Students were categorized into a WBLP group (n = 39) and a control group (n = 38). The WBLP group received structured formative assessments with mini-CEX and DOPS every 1–2 weeks, followed by immediate feedback. Outcomes included knowledge acquisition (multiple-choice question [MCQ] exam), clinical performance (6-station Objective Structured Clinical Examination [OSCE]), and perceptions of the learning environment (satisfaction questionnaire).

Results

Seventy-seven students were included. The WBLP group achieved significantly higher scores in both the MCQ exam (85.3 ± 6.1 vs. 80.2 ± 6.7, p < 0.001) and OSCE (86.4 ± 5.4 vs. 80.9 ± 5.9, p < 0.001), particularly in history taking, clinical reasoning, and procedural skills. No significant difference was observed in CPR performance. Students in the WBLP group reported greater satisfaction with feedback, patient communication, and overall learning experience (p < 0.01).

Conclusion

Integrating structured workplace-based assessments into clerkship training significantly enhances students’ clinical competence and improves their learning experience. These findings provide preliminary evidence to support broader implementation of WBLP in undergraduate medical curricula.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-026-08719-5.

Introduction

The development of clinical competence is a fundamental goal of undergraduate medical education and a key predictor of future patient care quality. Clinical competence entails the integration of medical knowledge, clinical reasoning, procedural skills, communication, and professionalism, applied in complex real-world settings [1]. Although clinical clerkships are a core component of medical curricula worldwide, traditional models—often characterized by unstructured observation, inconsistent supervision, and limited feedback—fail to ensure consistent skill acquisition and preparedness among students [2, 3].

To address these shortcomings, competency-based medical education (CBME) has emerged as a transformative framework, emphasizing clearly defined outcomes, staged progression, and the integration of performance-based assessments [4]. Within this model, workplace-based assessment (WBA) plays a central role by enabling the real-time evaluation of clinical performance in authentic settings. Compared to traditional, end-of-rotation summative exams, WBA facilitates formative, low-stakes observation and feedback that supports longitudinal growth [5].

Two validated tools central to WBA are the mini-Clinical Evaluation Exercise (mini-CEX) and the Direct Observation of Procedural Skills (DOPS). The mini-CEX evaluates students during brief, supervised encounters focusing on clinical reasoning, history-taking, and communication, while DOPS allows structured assessment of technical procedural skills. Both tools provide an opportunity for immediate feedback and reflection [6, 7]. Evidence suggests that regular use of these tools promotes better performance, encourages reflective learning, and enhances feedback quality [8, 9].

Despite these benefits, their integration into undergraduate clinical clerkships remains inconsistent. Internal medicine clerkships offer rich but pedagogically complex environments. The diversity of cases, fast-paced clinical routines, and inconsistent faculty involvement often result in unequal learning experiences and limited opportunities for direct observation [3]. Consequently, students may complete their rotations with gaps in clinical reasoning and technical proficiency.

Moreover, learner perception plays a significant role in clinical education outcomes. Satisfaction with the learning environment, opportunities for feedback, and teaching quality are all associated with student motivation, engagement, and skill development [10, 11]. While structured formative assessment has been shown to improve competence, its influence on student satisfaction remains underexplored. Some educators have raised concerns that increased observation may induce anxiety or disrupt workflow, whereas others argue it can foster confidence and engagement through meaningful feedback [12, 13].

Taken together, these gaps highlight the need for further evidence in undergraduate internal medicine education.In particular, it remains unclear how structured workplace-based learning interventions influence both objective clinical competence and students’ subjective learning experiences. Therefore, this study aimed to evaluate the effectiveness of a workplace-based learning program (WBLP) that integrated mini-CEX and DOPS into a 9-week internal medicine clerkship across six subspecialties. The program was designed to provide structured formative assessments every 1–2 weeks with immediate supervisor feedback. Outcomes were assessed across three domains: medical knowledge (via multiple-choice question [MCQ] exam), clinical competence (via Objective Structured Clinical Examination [OSCE]), and student perceptions of the learning environment (via questionnaire).

Methods

Study design and participants

This retrospective cohort study was conducted at Zhejiang University School of Medicine between September 2024 and May 2025. The protocol was reviewed by the Medical Ethics Committee of Zhejiang University School of Medicine, which granted a waiver of informed consent, as only de-identified data were analyzed and no personal identifiers were retained (Approval No. 2025-001). Seventy-seven fourth-year medical students undertaking their Internal Medicine clerkship were enrolled. Participants were retrospectively categorized into the test group (n = 39) and the control group (n = 38), according to whether they had undergone WBLP in addition to standard clerkship. The study flowchart is presented in Fig. 1. No students were excluded after enrollment. All 77 students completed the MCQ examination and OSCE assessment.

Fig. 1.

Flowchart of the overall study design

Study interventions

Both groups completed a 9-week clerkship across six internal medicine departments (Cardiology, Respiratory Medicine, Gastroenterology, Nephrology, Hematology, Endocrinology) with identical theoretical and clinical skills training. The test group additionally received a WBLP featuring structured formative assessments every 1–2 weeks using mini-Clinical Evaluation Exercises (mini-CEX) and Direct Observation of Procedural Skills (DOPS), with immediate feedback provided after each assessment. In contrast, the control group received only standard theoretical instruction and clinical skills training without additional assessments or feedback.

All assessments were performed by the same pool of 12 senior attending physicians (≥ 5 years of clinical teaching experience) who supervised both the intervention and control group students during their daily clinical work. Prior to study commencement, all participating supervisors attended a 8-hour consensus training workshop led by the principal investigator. The workshop covered standardized use of mini-CEX and DOPS rating forms, emphasis on formative intent, principles of high-quality feedback (timely, specific, behavior-focused, actionable, using ask-tell-ask or similar structured models), and strategies to integrate assessment with ongoing supervision and educational alliance building. Written guidance materials were distributed, and calibration was achieved through rating and discussing two video-recorded student–patient encounters.

Clinical competence evaluation

The evaluation indicators include a standardized multiple choice question (MCQ) examination and 6-station formative Objective Structured Clinical Examination (OSCE) [14], including history taking and clinical reasoning (Station 1–2), physical examination (Station 3–4), cardiopulmonary resuscitation (Cardiopulmonary Resuscitation [CPR], Station 5), bone marrow aspiration and thoracentesis (Station 6), respectively. Standardized patients (SP) trained to National Practitioners Examination standards were utilized for history taking and physical examination stations. The MCQ and OSCE scores were used to quantify knowledge acquisition and clinical proficiency, respectively.

Student satisfaction and perceptions of the learning experience were evaluated using a self-developed questionnaire adapted from previously published instruments assessing medical education learning environments and feedback quality [15–17]. The questionnaire consisted of seven domains reflecting students’ perceptions of the workplace-based learning experience, including interest in learning, in-depth study, independent study, self-confidence, teacher–student interaction, patient–doctor communication, and humanistic care. The English version of the questionnaire is provided as Supplementary File 1. For each domain, four items were included and rated on a 5-point Likert scale; domain scores were calculated as the mean of the four items and used for statistical comparison. A total of 77 questionnaires were distributed, and 75 valid questionnaires were returned (response rate: 97.4%). Two questionnaires were excluded from analysis due to incomplete responses.

Statistical analysis

Continuous variables were expressed as mean ± standard deviation (SD). Group comparisons were conducted using independent samples t-tests (or Mann–Whitney U tests for non-normally distributed data). Categorical variables were compared using χ² tests. Effect sizes (Cohen’s d) with 95% confidence interval (CI) were also calculated to facilitate interpretation. A two-tailed p < 0.05 was considered statistically significant. Given the exploratory nature of this educational study, no formal adjustment for multiple comparisons was applied. Analyses were performed using SPSS 33.0 (IBM Corp., Armonk, NY, USA). Figures were generated in GraphPad Prism 10.0 (GraphPad Software, San Diego, CA, USA).

Results

Population characteristics

In this retrospective dataset, 77 students were included (41 males, 36 females). Group assignment was based on whether students had participated in WBLP or standard clerkship. Baseline characteristics showed no statistically significant differences in gender distribution or pre-clerkship grade point average (GPA) between the two groups, indicating comparability (Table 1).

Table 1.

Basic characteristics of the two groups of students

Group	No.	Sex		Average GPA before clerkship
		Male	Female
WBLP	39	20	19	3.81/4
Control	38	21	17	3.79/4
χ2		0.12
P		0.72

GPA Grade-Point Average

Comparison of clinical competence

Participation in the WBLP was associated with a marked improvement in both theoretical knowledge and clinical performance. In the multiple-choice question (MCQ) examination assessing knowledge acquisition, The WBLP group achieved significantly higher MCQ scores than the control group (85.3 ± 6.1 vs. 80.2 ± 6.7; p < 0.001) (Fig. 2A). The effect size was large (Cohen’s d = 0.80, 95% CI 0.33–1.26), indicating a substantial difference in knowledge performance.

Fig. 2.

Mini-Cex and DOPS with immediate feedback improve students’ scores in MCQ and OSCE examinations. A MCQ test scores; (B) OSCE full scores; (C) Scores of history taking; (D) Scores of physical examination; (E) CPR scores; (F) Procedural skill scores

Similarly, performance in the 6-station formative OSCE, which evaluated various domains of clinical competence, was significantly better in the test group. The total OSCE score was higher among WBLP participants (86.4 ± 5.4 vs. 80.9 ± 5.9, p < 0.001; Cohen’s d = 0.97, 95% CI 0.50–1.45), reflecting overall enhanced clinical proficiency (Fig. 2B).

Subgroup analysis of OSCE station performance provided further insights. In Stations 1 and 2, which assessed history taking and clinical reasoning, students in the test group scored significantly higher than controls (Fig. 2C, p < 0.001). Similarly, in physical examination stations (Stations 3 and 4), the test group demonstrated significantly greater accuracy and technique (p < 0.05) (Fig. 2D).

No statistically significant difference was noted in Station 5 (CPR performance), where both groups performed comparably well (Fig. 2E). This likely reflects the high baseline familiarity with CPR due to prior mandatory skills sessions and its standardized, protocol-driven nature.

In contrast, the most pronounced performance gap was observed in Station 6, which tested procedural skills (bone marrow aspiration and thoracentesis). The test group scored substantially higher than the control group (Fig. 2F, p < 0.0001). This difference coincided with the inclusion of repeated direct observation and feedback during the clerkship.

Student feedback and satisfaction

Students’ perceptions of the learning experience were assessed through a structured post-clerkship satisfaction questionnaire covering seven domains: motivation, learning strategies (in-depth study and independent study), confidence, communication, humanistic care, and teacher-student interaction (Table 2). Analyses of student satisfaction were based on 75 complete questionnaires.

Table 2.

Comparison of the teaching satisfaction levels between the two groups of students (scores)

Group	Interest in learning	in-depth study	Independent study	self-confidence	Teacher– student interaction	Patient–doctor communication	humanistic care
WBLP*	4.74 ± 0.65	4.47 ± 0.89	4.13 ± 1.21	4.24 ± 0.91	4.39 ± 0.82	4.37 ± 0.85	4.18 ± 1.14
Control*	4.00 ± 1.29	3.97 ± 1.14	4.08 ± 1.09	3.78 ± 1.13	3.86 ± 1.13	3.84 ± 1.30	3.74 ± 1.42
t	2.02	2.12	0.19	1.91	2.32	2.09	2.4
p	0.047	0.037	0.85	0.060	0.023	0.040	0.019
Cohen’s d	0.73	0.49	0.04	0.40	0.54	0.48	0.34
95% CI	0.27–1.19	0.04–0.94		−0.03–0.83	0.08–0.99	0.03–0.94	−0.11–0.79

*full score for each section is 5; Cohen’s d and 95% CI reported for between-group comparisons

The WBLP group reported significantly higher levels of engagement and motivation. Specifically, scores for “interest in learning” (4.74 ± 0.65 vs. 4.00 ± 1.29, p = 0.047; Cohen’s d = 0.73, 95% CI 0.27–1.19) and “in-depth study” (4.47 ± 0.89 vs. 3.97 ± 1.14, p = 0.037; Cohen’s d = 0.49, 95% CI 0.04–0.94) were significantly elevated. Although the test group also showed a slight increase in “independent study” scores, the difference was not statistically significant (p = 0.85). Self-reported confidence in clinical settings was higher in the test group (4.24 ± 0.91) than in the control group (3.78 ± 1.13), approaching but not reaching statistical significance (p = 0.060; Cohen’s d = 0.40, 95% CI − 0.03–0.83). Notably, interpersonal and communication aspects of the learning environment also improved with WBLP implementation.The WBLP group reported significantly better “communication with patients” (4.37 ± 0.85 vs. 3.84 ± 1.30, p = 0.040; Cohen’s d = 0.48, 95% CI 0.03–0.94) and “teacher–student interaction” (4.39 ± 0.82 vs. 3.86 ± 1.13, p = 0.023; Cohen’s d = 0.54, 95% CI 0.08–0.99). In addition, perceptions of humanistic care training were more favorable in the WBLP group (4.18 ± 1.14 vs. 3.74 ± 1.42, p = 0.019; Cohen’s d = 0.34, 95% CI − 0.11–0.79).

Discussion

This study examined the impact of a workplace-based learning program integrated into an undergraduate internal medicine clerkship. Students who participated in the WBLP achieved higher MCQ and OSCE scores than those in the control group, with differences most apparent in history taking, clinical reasoning, physical examination, and procedural skills. While mini-CEX and DOPS have been widely used in medical education, relatively few studies have examined their structured and longitudinal use, with regular opportunities for direct observation and feedback, in undergraduate internal medicine clerkships.

Formative WBA impacts WBLP via mechanisms including immediate specific feedback from direct observation [18], promotion of self-regulated learning through actionable feedforward [19], and reinforcement of competencies in authentic settings [20]. Critical enabling conditions include supervisor training in structured feedback delivery and trust-building [21]. Our intervention aligned with these by emphasizing immediate dialogues, formative tools, and supervisor briefings, though enhanced faculty development remains a future opportunity. This aligns with an implicit CIMO logic (Context-Intervention-Mechanism-Outcome), where in a high-workload clerkship context (C), regular formative WBA by trained supervisors (I) may trigger immediate feedback and self-regulation mechanisms (M) to yield enhanced competence and engagement (O) [18].

Our findings showed higher MCQ and OSCE scores among students who participated in the WBLP. Differences were most apparent in history taking, clinical reasoning, physical examination, and procedural skills. These findings are consistent with existing literature on workplace-based assessment, while extending prior evidence by focusing specifically on undergraduate students in an internal medicine clerkship setting. A systematic review and meta-analysis reported positive effects of mini‑CEX and DOPS on trainee performance (Kirkpatrick Level 2b), with standardized mean differences of 0.26 for mini‑CEX (p = 0.014) and 3.33 for DOPS (p < 0.001) [22]. Another interventional study among final-year medical students corroborated improvements in clinical competencies over time and high satisfaction among both students and supervisors when using mini‑CEX and DOPS [23]. The observed improvement in clinical competence is most likely attributable to the combined effect of several core elements of the WBLP, including regular direct observation of authentic clinical performance using structured tools (mini-CEX and DOPS), frequent, low-stakes formative assessments (every 1–2 weeks), and immediate, behavior-specific feedback provided by trained supervisors.

The significant gains in procedural skills—bone marrow aspiration and thoracentesis—may be explained by the direct observation and immediate feedback inherent in DOPS. One study in radiology education demonstrated that DOPS substantially improved practical and clinical skills as well as self-confidence compared to conventional assessment methods (p = 0.001) [24]. Similarly, a systematic review found that DOPS effectively enhanced practical skill acquisition in dentistry and nursing, attributed in part to the motivation fostered by the assessment format [25]. The absence of a significant difference in CPR skills between groups likely reflects a ceiling effect due to uniformly high baseline exposure and emphasis across both groups, supplemented by dedicated simulation-based training outside the WBLP framework.

In addition to objective competence measures, this study evaluated students’ subjective perceptions of learning through satisfaction questionnaires, revealing that students in the WBLP group reported higher levels of interest in learning and engagement in in-depth study. Participants reported significantly higher ratings of teacher–student interaction and patient communication, which may reflect positive experiences with formative workplace assessment. This finding is supported by literature showing that feedback-rich environments enhance motivation, professional identity formation, and self-regulated learning behaviors [15, 26]. Although the increase in self-confidence did not reach statistical significance, the observed trend suggests that repeated direct observation combined with constructive feedback could help students feel more competent in clinical encounters.

Notably, independent study behaviors were not significantly affected by the intervention. This may reflect the structured nature of the clerkship and the emphasis on supervised clinical activities. In contrast, self-directed learning is likely influenced by additional factors, such as individual study habits and institutional support. Future program refinements could incorporate explicit goal-setting exercises or reflective portfolios to strengthen students’ capacity for independent study. The findings of this study further suggest that the positive impact of workplace-based assessment may depend not only on assessment frequency and format but also on other contextual factors, which could include feedback processes and the educational environment. The consistently high satisfaction reported here aligns with previous evidence showing that learners value formative assessments when they perceive feedback as credible, timely, and relevant to their professional development [12, 13]. Moreover, the improvement in humanistic care ratings may indicate that workplace-based assessment has the potential to reinforce professionalism and empathy, essential domains of clinical competence sometimes neglected in traditional instruction.

Several limitations of this study should be acknowledged. First, the relatively small sample size and single-center design may limit the generalizability of the findings. Second, although all supervisors received standardized training and used the same rating forms, we did not formally measure fidelity of feedback delivery or long-term maintenance of assessor calibration, which could be addressed in future implementation studies. Third, the multifaceted nature of the intervention means that the present study was not designed to disentangle the individual effects of specific assessment tools, feedback frequency, or supervisor characteristics. Finally, increased attention to assessment activities may have influenced students’ perceptions and behaviors.

In conclusion, this study demonstrates that structured formative workplace-based assessments with direct observation and feedback are associated with improved clerkship students’ clinical competence and learning experience, supporting broader integration of WBLP to develop technical skills, motivation, communication, and professionalism. Longitudinal research and curricular refinements remain essential. Key actionable steps include faculty development for timely, specific, actionable feedback and trust-building, alongside incorporating self-reflection, feedforward planning, and follow-up opportunities to strengthen self-directed learning and sustainable competency-based education.

Abbreviations

CBME

Competency-Based Medical Education

CI

Confidence Interval

CPR

Cardiopulmonary Resuscitation

DOPS

Direct Observation of Procedural Skills

GPA

Grade Point Average

MCQ

Multiple-Choice Question

mini-CEX

mini-Clinical Evaluation Exercise

OSCE

Objective Structured Clinical Examination

SD

Standard Deviation

SP

Standardized Patient

WBA

Workplace-Based Assessment

WBLP

Workplace-Based Learning Program

Authors’ contributions

Ji-nuo Wang and Hanbing Lv conceived and designed the study. Hanbing Lv, Yi Sun, and Luhua Jiang coordinated the clerkship interventions and data collection. Ji-nuo Wang and Wen Cao performed the statistical analysis and contributed to result interpretation. Ji-nuo Wang drafted the manuscript. All authors critically revised the manuscript and approved the final version.

Funding

This study was supported by the “AI for Education” Project of Zhejiang University (For Ji-nuo Wang) and the Medical Education Reform Project of Zhejiang University, School of Medicine (Grant No. jgzx2025009 for Ji-nuo Wang).

Data availability

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

Declarations

Ethics approval and consent to participate

All data were anonymized prior to analysis: personal identifiers such as names, student ID numbers, and other potentially identifying information were removed. Only aggregated or coded data were used for statistical analyses, ensuring that individual students could not be identified. The study was assessed by the Medical Ethics Committee of Zhejiang University, School of Medicine, which granted a waiver of formal ethical approval (No. 2025-001). Informed consent was deemed not required by the Medical Ethics Committee of Zhejiang University School of Medicine, as only anonymized educational data were used. The study was conducted in accordance with the principles of the Declaration of Helsinki (2013 revision).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.