Impact of the COVID-19 pandemic on the clinical performance of medical students: a retrospective study in Korea

Yu, Jihye; Lee, Sukyung; Lee, Janghoon; Park, Inwhee; Jihye Yu; Sukyung Lee; Janghoon Lee; Inwhee Park

doi:10.3946/kjme.2025.331

Korean J Med Educ > Volume 37(2); 2025 > Article

Yu, Lee, Lee, and Park: Impact of the COVID-19 pandemic on the clinical performance of medical students: a retrospective study in Korea

Original Research

Korean J Med Educ 2025; 37(2): 143-152.

Published online: May 29, 2025

DOI: https://doi.org/10.3946/kjme.2025.331

Impact of the COVID-19 pandemic on the clinical performance of medical students: a retrospective study in Korea

Jihye Yu¹

, Sukyung Lee²

, Janghoon Lee³

, Inwhee Park⁴

¹Department of Medical Education, Ajou University School of Medicine, Suwon, Korea

²Ajou Center for Clinical Excellence, Ajou University School of Medicine, Suwon, Korea

³Department of Pediatrics, Ajou University School of Medicine, Suwon, Korea

⁴Department of Nephrology, Ajou University School of Medicine, Suwon, Korea

Corresponding Author: Inwhee Park (https://orcid.org/0000-0002-9912-5393) Department of Nephrology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82.31.219.5131 Fax: +82.31.219.4567 email: inwhee@ajou.ac.kr

Received December 3, 2024 Revised February 25, 2025 Accepted April 14, 2025

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

The COVID-19 (coronavirus disease 2019) pandemic led to significant changes in clinical clerkships, including reduced ward rounds. We aimed to determine how the pandemic–induced changes in the clinical practice environment affect the clinical performance of medical students.

Methods

We analyzed objective structured clinical examination scores of third- and fourth-year medical students from 2019–2020 and 2020–2021 across six stations by the Seoul–Gyeonggi Consortium. Clinical, communication, and ability scores were measured and analyzed using repeated-measures multivariate analysis of variance.

Results

The interaction between clinical practice progress and pandemic-induced changes significantly affected physical examination and medical history scores, though the differences were not substantial. Patient-physician interaction significance varied by measurement period. Clinical communication ability also showed significant differences based on the measurement period and practical experience.

Conclusion

During the pandemic, alternative learning methods, including self–learning, simulation/practice, and peer role–play, helped improve medical competency in areas such as history–taking and physical examination. However, these were less effective in improving patient–physician interactions or clinical communication efficacy. Alternative learning methods have limitations, and they cannot replace direct patient encounters in clinical practice.

Keywords: COVID-19, Clinical clerkship, Clinical communication skills, Clinical performance, Medical student

Introduction

Clinical practice is crucial in medical education, as it represents the process of training medical students to attend to patients in real world clinical settings to gain appropriate clinical competency [1,2]. Physician–patient encounters are essential for improving medical students’ clinical skills and are the most essential part of clinical practice [2]. Therefore, clinical rotations are imperative in the medical school curricula.

The coronavirus disease 2019 (COVID-19) pandemic has considerably changed education and significantly affected clinical practice in medical education. With the rapid spread of the virus, the Association of American Medical Colleges issued guidelines prohibiting medical students from clinical rotations and strongly recommended their nonparticipation in direct patient care activities [3,4]. To ensure patient and student safety, medical schools postponed clinical practice and banned direct contact with patients, thereby reducing the duration of students’ clinical practice and limiting the practice site and content [5,6]. Several medical schools have attempted to replace students’ actual patient care experiences by introducing various alternative learning methods, such as scenariobased simulations and virtual learning using simulators, to compensate for the learning loss caused by reduced clinical practice due to the pandemic [6,7]. However, the alternative learning methods implemented to compensate for the absolute decrease in students’ opportunities to encounter patients directly due to hospital–imposed restrictions during the pandemic have exhibited limitations in supplementing their reduced clinical experience [8]. Although the COVID-19 pandemic has ended, its impact on medical education persists. Many institutions continue to explore alternative learning methods to address potential future disruptions [9,10]. This study provides critical insights into the effectiveness of these alternative educational approaches and highlights areas that require further development to ensure comprehensive clinical training.

Regarding medical students’ perceptions of the impact of the COVID–19 pandemic, research has revealed that the reduced and limited clinical practice of medical students has negatively affected their clinical performance and readiness in real world clinical settings [11]. Medical students perceive clinical clerkships, such as physician– patient encounters and receiving direct feedback on clinical performance, as indispensable and irreplaceable processes [12,13]. Therefore, verifying the effects of the COVID-19 pandemic on medical students’ clinical performance is crucial.

The objective structured clinical examination (OSCE) is a comprehensive and standardized tool that measures the clinical competencies of medical students with proven validity and reliability [14]. Measuring clinical communication skills plays a significant role in identifying clinical competencies because communication between physicians and patients is important for providing excellent medical care. Therefore, we aimed to confirm the impact of the pandemic on medical students’ clinical performance by comparing and analyzing the scores for skills such as history–taking, physical examination, patient –physician interaction, and clinical communication abilities of medical students who underwent clinical practice during the COVID-19 pandemic and under normal conditions. By analyzing the effect of changes in the clinical practice environment due to COVID-19 restrictions on the clinical performance of medical students, we intended to confirm the effect of alternative education modules, such as remote and virtual learning, on medical students’ clinical performance during the pandemic.

The following are the specific research questions pertaining to the purpose of this study: (1) Based on the clinical practice experiences of third– and fourth–year medical school students who underwent clinical practice from 2019–2020 versus 2020–2021, is there any difference in the change patterns of their OSCE scores? (2) Is there a difference between the change patterns in the communication assessment tool (CAT) scores of the clinical practice experiences of third– and fourth–year students in 2019–2020 and 2020–2021?

Methods

1. Design

In this study, we retrospectively analyzed the OSCE and CAT scores of cohorts of medical students who underwent clinical practice during the COVID-19 pandemic and those who experienced general clinical practice to compare and analyze their scores in skills such as history–taking, physical examination, patient–physician interaction, and clinical communication abilities.

2. Ethical considerations

This study was approved by the Institutional Review Board of Ajou University Hospital (approval no., AJOU IRB-SUR-2021-621).

3. Data collection

From April 1 to 28, 2022, we collected and analyzed OSCE and CAT scores from the 2019–2020 and 2020–2021 academic years for third- and fourth-year medical students at Ajou University School of Medicine. The study participants underwent essential clinical clerkships in internal medicine, surgery, obstetrics, pediatrics, and psychiatry in their third year. The fourth year consisted of an elective course as well as other modules such as clinical clerkship, research, and sub-internships. The students in the 2020–2021 cohort underwent a reduced clinical practice period due to reduced academic schedules, including a temporary vacation in February 2020 due to the COVID-19 pandemic, remote classes, and simulation practices (with simulators). Furthermore, clinical practice was excluded from ward practice and was limited to outpatient hospital appointments, treatment rooms, workrooms, and emergency room screening clinics. The collected OSCE scores were divided into 2020–2021 (N=40) and 2019–2020 (N=43) school–year cohorts, and the evaluation times for each cohort were as follows: Time 1, after the third year of internal medicine practice; Time 2, after the third year of full practice; and Time 3, after the fourth year of full practice. The CAT scores were also divided into 2020–2021 (N=37) and 2019–2020 (N=43) school–year cohorts, and each cohort was evaluated at Time 1, before the third year of clinical practice; Time 2, after the third year of full practice; and Time 3, after the fourth year of full practice.

4. Outcome measures

1) Objective structured clinical examination

In Korea, the OSCE, also known as the clinical performance examination, is administered to evaluate student doctors’ performance in the diagnosis, prescription, and education of standardized patients within a given period according to the treatment situation. The OSCE consists of six stations, each of which evaluates the treatment performance of standardized patients for 10 minutes. Each station was evaluated according to checklist items, with scores ranging from 0 to 100. We collected scores for three areas (history–taking, physical examination, and patient– physician interactions) and used them for the analysis of the 10–minute evaluation of students’ treatment of standardized patients organized by the Seoul–Gyeonggi Consortium. History–taking was evaluated using “yes” (1) or “no” (0); physical examination, using “properly done” (2), “not properly done” (1), and “not done” (0); and patient– physician interactions, using “excellent” (3), “good” (2), “normal” (1), and “insufficient” (0).

2) Communication assessment tools

To measure students’ clinical communication skills, we used the CAT [14], a scale composed of 14 questions, each measured on a 5-point Likert scale ranging from “poor” (1) to “excellent” (5). Higher total scores indicate greater student communication ability.

5. Statistical analysis

We conducted an independent–samples t-test to verify the homogeneity across the cohorts of measurement variables. We performed repeated measures multivariate analysis of variance and repeated measures analysis of variance to compare the differences in the OSCE and CAT scores based on the measurement period of each cohort. All analyses were performed using IBM SPSS Statistics for Windows ver. 25.0 (IBM Corp., Armonk, USA).

Results

1. Changes in the OSCE scores during clinical practice

Table 1 presents the OSCE scores collected at three time points: after internal medicine practice, after the full third-year practice, and after the full fourth-year practice. Descriptive statistics are provided for the domains of history-taking, physical examination, and patient –physician interaction by time point and cohort. Figs. 1 through 3 display the changes in OSCE scores over time for each cohort.

2. Changes in OSCE scores by the presence or absence of COVID-19

Table 2 presents the changes in the OSCE scores based on the progress of the clinical practice processes as well as the differences in the practice experience before and during the pandemic. We observed statistically significant differences in history-taking, physical examination, and patient–physician interaction scores based on the OSCE measurement period. The comparison of the effect size according to time showed that the effect sizes were highest in the order of physical examination, patient–physician interaction, and history–taking.

The interaction between time and cohort was significant for physical examination, and the effect size exceeded 0.14, which can be interpreted as sufficiently large. However, we found no statistically significant interaction between time and cohort in the history–taking scores. For patient–physician interactions, both the time effect and the interaction between time and cohort were statistically significant, indicating changes across time and between cohorts.

3. Changes in CAT scores during clinical practice

CAT scores were collected three times: during and before clinical practice, and after the third– and fourth– year practice (Table 3). Trends in CAT scores are further presented in Fig. 4, which compares the progression in communication ability over time between cohorts.

4. Changes in CAT scores by the presence or absence of COVID-19

Table 4 presents the changes in the CAT scores based on the progress of the clinical practice process and the differences in practice experiences owing to the presence or absence of the pandemic. The scores for clinical communication ability obtained using the CAT exhibited different significance values based on the measurement period. Furthermore, the interaction between the time and cohort exhibited statistically significant differences by the measurement period. At Times 2 and 3, the regular and pandemic–affected cohorts exhibited increasing and decreasing trends, respectively.

Discussion

The history –taking and physical examination scores of the cohort that underwent clinical practice during the COVID–19 pandemic period were similar to or higher than those of the cohort that underwent pre–COVID–19 practice, although this was not the case for patient– physician interactions and clinical communication efficacies.

As the COVID-19 pandemic restricted ward practice and reduced medical students’ opportunities to directly encounter patients, medical schools and hospitals implemented various alternative learning methods, such as self–learning through medical treatment guidebooks, simulation practice using models and simulators, and peer role play [15-17]. In the OSCE, history–taking scores pertain to responses to questions on determining diseases based on medical knowledge of patients’ symptoms. Additionally, the physical examination questions in the OSCE were designed to evaluate whether students had acquired clinical skills and mastered related cases. Therefore, high history-taking and physical examination scores on the OSCE could be attained through other learning methods aimed at replacing patient–encounter clinical practice in hospitals. When hospital practice was inevitably restricted due to the pandemic, medical schools strove to introduce and implement various alternative learning methods in medical education, such as prerecorded videos, live lectures, and scenario-based simulations [7,18]. Our findings align with previous studies indicating that reduced clinical exposure during the pandemic led to decreased confidence in patient interactions and communication skills [19]. However, unlike prior studies, our research demonstrates that history-taking and physical examination skills remained relatively unaffected, likely due to the implementation of alternative learning methods such as simulation-based training and virtual patient encounters. This suggests that while alternative learning methods can compensate for certain skill deficits, they are insufficient for fostering patient-centered communication and interaction skills.

Our results showed that students obtained high scores on history–taking and physical examination but not on patient–physician interaction or clinical communication. Consistent with previous studies [20,21], our findings suggest an increased reliance on self-directed learning methods among medical students during the COVID-19 pandemic. This shift may be attributed to the transition toward remote learning environments during the pandemic. Although e-learning has been reported to be effective in supplementing face-to-face clinical instruction in the context of limited face-to-face clinical practice, student perceptions of its effects tended to be neutral [13]. While online platforms provide flexibility and access to diverse learning resources, they often lack the interactive and experiential aspects of direct patient encounters, which are essential for developing clinical communication skills and building patient-physician rapport. Previous studies have indicated that students perceive improvements in their clinical competencies through e-learning interventions, though their perceptions of its overall effectiveness tend to remain neutral [13]. This suggests that while online learning offers certain advantages, it has limitations in enhancing clinical competencies. Direct patient encounters and clinical experiences in real-world settings are essential components of medical education, highlighting the need for in-person clinical training to effectively develop practical skills and professional communication abilities.

Our results showed that students obtained high scores on history–taking and physical examination but not on patient–physician interaction or clinical communication. Several factors may have contributed to the decline in clinical communication skills among medical students during the COVID-19 pandemic. The lack of face-to-face interactions significantly limited opportunities for students to engage in real-time communication with patients, peers, and instructors [22]. Non-verbal communication elements such as eye contact, body language, and facial expressions, which are essential for building rapport with patients, were difficult to practice in online learning environments. This reduction in direct interaction hindered the development of effective clinical communication skills. In addition, the cancellation or reduction of clinical clerkships and simulation-based training prevented students from gaining hands-on experience in patient care. Practical opportunities to apply communication techniques, such as empathy, active listening, and conveying complex medical information in a clear and compassionate manner, were severely diminished [23]. Without these experiential learning opportunities, students were unable to practice and refine their communication skills in real-world clinical settings. In terms of self-reported clinical communication abilities, students who underwent clinical practice during the pandemic tended to show relatively low improvements in their scores. Medical students’ clinical communication skills were underdeveloped when they lacked clinical experience [6]. Moreover, research has noted that students acquire clinical communication skills through aspects of clinical practice, such as actual patient interviews and learning from role models, such as professors and residents [24]. Students also expressed a desire to learn clinical communication skills through practical experiences such as communicating with patients in real world clinical settings [25]. Additionally, ward rounds enhance medical capabilities, including knowledge, skills, and clinical communication by offering opportunities for doctors and trainees to participate in discussions on inpatient conditions and treatment plans [26-30]. In this context, the prohibition, reduction, and restriction of ward practice during the pandemic might have negatively affected students’ OSCE scores and self–efficacy in clinical communication with patients. These results highlight the continuous need to provide meaningful patient interaction opportunities even in remote learning environments to ensure the development of effective clinical communication skills.

Our findings offer important implications for the future of medical education in the post-COVID-19 era. Integrating hybrid learning models that combine online education with in-person clinical training can enhance both theoretical knowledge acquisition and practical skill development. Although alternative learning methods, such as simulation-based training and virtual patient encounters, have proven effective for specific skills, they are insufficient for fostering comprehensive patientcentered communication and clinical decision-making abilities. Medical curricula should be designed with flexibility to adapt quickly to future public health emergencies, ensuring that essential clinical training continues without compromising the safety of students or the quality of education.

The limitations of this study are as follows. This was a single center study with a relatively small sample size. Moreover, the OSCE and clinical communication ability scores may have been influenced by other confounding variables besides the presence or absence of clinical practice experience during the COVID-19 pandemic. As this was a retrospective study, the educational experience in each clinical practice and individual variables of the students could differ. Another limitation is that the OSCE and CAT scores, which we employed as measures to evaluate the clinical performance of medical students, did not include all the elements of clinical competency. Therefore, the results cannot be generalized.

Learning is most effectively achieved by experiencing the actual field in which the acquired knowledge is applied to meet field requirements [31]. During the COVID-19 pandemic, an unprecedented event in terms of scale, medical education excluded clinical practice because student preparation and responses to the pandemic were deemed inadequate. However, as no alternative learning method can replace face-to-face encounters with patients, other options that allow medical students to participate in the activities of hospitals and develop their clinical capabilities, even during a crisis such as a pandemic, must be explored.

Notes

Acknowledgements

None.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Author contributions

JY and IP developed the study concept and design. JY analyzed and interpreted the data and drafted the manuscript. SL acquired the data. JL assisted with the data interpretation and revised the manuscript. IP critically revised the manuscript and supervised the study. The manuscript has been read and approved by all the authors, that the requirements for authorship have been met, and that each author believes that the manuscript represents honest work.

Fig. 1.

Changes in History-Taking Scores over Time

Time 1: after the third year of internal medicine practice; Time 2: after the third year of practice; Time 3: after the fourth year of practice. Cohort 1: 2020–2021 (pandemic-affected); Cohort 2: 2019–2020 (unaffected).

Fig. 2.

Changes in Physical Examination Scores over Time

Fig. 3.

Changes in Patient–Physician Interaction Scores over Time

Fig. 4.

Changes in CAT Scores over Time

Time 1: before 3rd-year clinical practice; Time 2: after 3rd-year clinical practice; Time 3: after 4th-year clinical practice. Cohort 1: 2020–2021 (pandemic-affected); Cohort 2: 2019–2020 (unaffected). CAT: Clinical communication ability.

Table 1.

Descriptive Statistics of Objective Structured Clinical Examination Scores by Domain, Time Point, and Cohort

Domain	Assessment time point	Cohort	Mean±SD score
History–taking	Time 1	Cohort 1	58.96±6.81
		Cohort 2	61.68±7.22
	Time 2	Cohort 1	68.23±9.15
		Cohort 2	69.77±7.08
	Time 3	Cohort 1	66.16±6.87
		Cohort 2	66.18±7.46
Physical examination	Time 1	Cohort 1	37.59±15.09
		Cohort 2	36.89±10.92
	Time 2	Cohort 1	66.25±11.35
		Cohort 2	45.72±11.89
	Time 3	Cohort 1	49.73±11.19
		Cohort 2	47.35±10.00
Patient–physician interaction	Time 1	Cohort 1	69.22±11.47
		Cohort 2	61.39±6.08
	Time 2	Cohort 1	72.69±8.26
		Cohort 2	76.02±8.07
	Time 3	Cohort 1	68.33±9.19
		Cohort 2	70.88±7.26

SD: Standard deviation.

Table 2.

Repeated-Measures Multivariate Analysis of Variance of Objective Structured Clinical Examination Scores between Cohorts (Only Significant Results)

Within-subject effects	Factors	Time	df	Mean square	F	p-value	Effect size (η²)
Time	History–taking	1 vs. 2	1	6,238.680	70.082	0.000	0.464
		2 vs. 3	1	661.386	8.090	0.006	0.091
	Physical examination	1 vs. 2	1	29,129.667	131.723	0.000	0.619
		2 vs. 3	1	4,589.960	27.780	0.000	0.255
	Patient–physician interaction	1 vs. 2	1	6,788.473	82.402	0.000	0.504
		2 vs. 3	1	1,871.741	25.924	0.000	0.242
Time*Group	Physical examination	1 vs. 2	2	8,147.325	36.842	0.000	0.313
		2 vs. 3	2	6,828.380	41.328	0.000	0.338
	Patient–physician interaction	1 vs. 2	2	2,578.060	31.294	0.000	0.279

Time 1: after third-year internal medicine practice; Time 2: after all third-year practice; Time 3: after all fourth-year practice. Cohort 1: 2020–2021 (pandemic-affected); Cohort 2: 2019–2020 (unaffected).

df: Degrees of freedom.

Table 3.

Descriptive Statistics of Clinical Communication Ability Scores by Time Point and Cohort

Assessment time point	Cohort	Mean±SD score
Time 1	Cohort 1	3.76±0.57
	Cohort 2	3.71±0.55
Time 2	Cohort 1	4.00±0.48
	Cohort 2	4.05±0.58
Time 3	Cohort 1	3.87±0.41
	Cohort 2	4.17±0.48

SD: Standard deviation.

Table 4.

Repeated-Measures Analysis of Variance of CAT Scores by Time Point and Cohort (Significant Results Only)

Within-subject effects	Factors	Time	df	Mean square	F	p-value	Effect size (η²)
Time	CAT	1 vs. 2	1	6.723	21.347	0.000	0.215
Time*Group	CAT	2 vs. 3	1	1.147	5.594	0.021	0.067

Time 1: before 3rd-year clinical practice; Time 2: after 3rd-y ear clinical practice; Time 3: after 4th-year clinical practice. Cohort 1: 2020–2021 (pandemic-affected); Cohort 2: 2019 –2020 (unaffected).

CAT: Clinical communication ab ility, df: Degrees of freedom.

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