Research papers
Bene®ting from clinical experience: the in¯uence
of learning style and clinical experience on performance
in an undergraduate objective structured clinical examination
Iain G Martin,1 Patsy Stark2 & Brian Jolly3
Objective To assess the relationship between clinical
experience, learning style and performance in an
objective structured clinical examination (OSCE) in
medical students at the end of their ®rst clinical year.
Design Prospective study of undergraduate students
taking an OSCE examination at the end of their ®rst
clinical year.
Subjects 194 undergraduate medical students (95
male).
Main Outcome Measures Performance in the OSCE
examination, the Entwhistle Learning Style Inventory1
and a composite self-reported score of clinical activity
during the students ®rst clinical year.
Results Performance in the OSCE examination was
related to well-organized study methods but not to
Introduction
Medical training, which until recently has been based
upon the apprentice/master model, is in a period of
considerable change. The GMC's document, Tomor-
row's Doctors2 is leading to radical change within the
undergraduate medical curriculum. The traditionally
overburdened curriculum is being pared down to that
which is considered core, with as much as 30% of the
course being devoted to special study modules. Whilst
these new curricula offer many opportunities, the ed-
ucators of the next generation of doctors must produce
graduates skilled in clinical medicine. Traditionally,
clinical competence has been developed from periods of
experience on wards, however, the relationship between
1
Senior Lecturer in Surgery, Undergraduate Surgical Education
Co-ordinator, 2Director, Clinical Skills Centre, 3Director, Medical
Education Unit, Division of Surgery & Department of Medical Edu-
cation, Leeds University Medical School, Leeds, UK
Correspondence: Iain G Martin, Academic Department of Surgery, The
General In®rmary at Leeds, Great George Street, Leeds LS1 3EX,
UK
530 Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2000;34:530±534
clinical experience. A signi®cant relationship between
clinical experience and organized deep-learning styles
suggests that knowledge gained from clinical experience
is related to learning style.
Conclusions The relationship between clinical ex-
perience and student performance is complex.
Well-organized and strategic learning styles appear to
in¯uence the bene®ts of increased clinical exposure.
Further work is required to elucidate the most bene®-
cial aspects of clinical teaching.
Keywords Undergraduate medical education, *meth-
ods; medical students, *psychology; *learning; clinical
medicine, *education; educational measurement,
methods; prospective studies.
Medical Education 2000;34:530±534
clinical experience of students and their subsequent
performance has always been recognized as complex. It
is important that we understand how students bene®t
from clinical experience and what types of experience
are most bene®cial.
The need to accurately assess a student's clinical
abilities is of great importance if we are to be certain
that the new curricula are meeting our objectives. Not
only do we need to ensure that we produce competent
graduates, but that they will continue to learn from
experience throughout their professional careers and
embody the characteristics of SchoÈn's Re¯ective Practi-
tioner.3 The assessment methods that we choose for our
students must encourage both the development of the
clinical skills we require and reward the type of deep
and meaningful learning we value. To date, there
appears to be no clear relationship between clinical
experience and either performance in an OSCE exam-
ination4 or surgery exit examinations.5 McManus6 has
recently demonstrated a lack of correlation between the
results of traditional ®nal year examinations and clinical
experience and has suggested that alternative methods
of assessment should be explored.
Clinical experience and performance in an undergraduate OSCE
In 1995, we introduced an OSCE examination at the
end of the ®rst clinical year (year 3), both to emphasize
to students the importance of clinical skills and to assess
their acquisition of these fundamental tools of their
future career. The examination is run jointly by the
Divisions of Medicine and Surgery and although not a
degree level examination, failure in the examination
may result in failure to progress to year 4 of the course.
The examination consists of 24 stations assessing a
broad range of clinical skills ± history taking,
examination skills, communication skills, practical
procedures (e.g. venepuncture and basic life support,
electrocardiographic tracing's and patient observation
charts). Whilst recognizing the limitation of such an
examination in that it breaks down the clinical process
into a series of discrete steps, the OSCE has been
shown to be a representative, fair assessment of stu-
dent's clinical abilities.7 It should reward students who
use their clinical exposure wisely and should not
encourage surface learning of rote fact. The aim of this
study was to assess the relationship between the stu-
dent's learning style, clinical experience and their per-
formance in the examination.
Subjects and methods
The current Leeds undergraduate curriculum has two
preclinical years followed by three predominantly clin-
ical years. The third year course, run jointly by the
Divisions of Medicine and Surgery, aims to teach the
students key clinical skills and, coupled with a course in
laboratory and scienti®c medicine, is designed to give
the student a fundamental grasp of the clinical practice
of medicine. The clinical component comprises
attachments to four clinical ®rms, with one day a week
devoted to formal clinical skills teaching run jointly by
the divisions of medicine and surgery.
In the academic session 1997±98, 194 students were
taught and examined. As described above, the exami-
nation took the form of a 24 station OSCE.
To assess the student's learning style, the learning
style inventory of Entwhistle1 was used. This 30 ques-
tion inventory, which has been used in the evaluation of
medical students previously,8,9 has three principle and
four supplementary components: an achieving scale, a
reproducing scale (surface learning) and a meaning
scale (deep learning) being the ®rst three, and com-
prehension learning, operation learning, versatile
approach and learning pathologies the subsequent four
components. Entwhistle also described a composite
score described as an overall predictor of academic
success. Students were asked to complete this inventory
within 1 week of the examination.
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· I G Martin et al. 531
Clinical experience
The students were asked to report, in a questionnaire,
three important aspects of their clinical experience dur-
ing the year. Firstly the total number of patients clerked,
secondly the number of outpatient clinics attended and
thirdly the number of emergency `takes' the student
attended. For each of the parameters, the students were
given options of various levels of activity. For the num-
bers of patients clerked this varied from 5 or less through
to more than 40, for numbers of outpatients attended this
varied from less than 5 to more than 20 and for number of
emergency takes, from none to more than 10. The an-
swers were grouped to give a numerical score and the
total amount of clinical experience was taken as a com-
bined score for the three areas of clinical activity.
Statistical analysis
Statistical analysis was performed using SPSS 7á5 for
Windows. Correlation coef®cients between OSCE
scores or clinical experience and the learning style
inventory data were reported both `raw' and adjusted
for attenuation.10
Results
OSCE
The mean mark for the OSCE examination was 76%
(range 56±92%). The reliability coef®cient (Cronbach's
alpha) for the OSCE examination was 0á702. For the
history, examination, data interpretation and practical
skills subsections of the OSCE examination the reli-
ability coef®cients were 0á519, 0á593, 0á321 and 0á432,
respectively, largely re¯ecting the smaller numbers of
stations in each subsection.
Learning style
Of the 194 students, 150 (77%) returned a completed
form. Reliability coef®cients for the achieving scale, the
reproducing scale and the meaning scale were 0á53,
0á49 and 0á49, respectively.
Clinical experience
There was substantial variation in the reported clinical
experience: the mean clinical activity score was 11á2, with
a range of 5±16. The numbers of patients clerked varied
from between 6 and 10 to 30±40, the number of outpa-
tient clinics between 0 and 5 and more than 20 and the
number of emergency takes between 0 and more than 10.
532 Clinical experience and performance in an undergraduate OSCE · I G Martin et al.

Table 1 Correlation between learning

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

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

Learning style and clinical experience

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

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Clinical experience and performance in an undergraduate OSCE
of the OSCE examination (Table 2), most notably the
history stations, but the absolute differences were small.
The overall mean percentage scores were 77 and 75%,
respectively (P ˆ 0á011, independent samples t-test).
There were no differences at all in learning style or
clinical experience reported between the male and
female students.
Discussion
McManus6 has recently shown that performance in the
traditional ®nals examination does not re¯ect clinical
experience and that there appeared to be a positive
relationship between strategic learning styles and
examination performance. This study was conceived to
look further at this complex relationship in students at
the beginning of their clinical careers. By examining a
large number of discrete clinical skills which, it is
thought, are acquired largely by direct clinical experi-
ence, the OSCE should provide a broader based
assessment of the student's clinical abilities. Does
greater clinical experience result in increased perfor-
mance in our OSCE examination? The simple answer is
no. Notably, our results re¯ect closely those of
McManus6 ± as with the traditional ®nals examination
± there is no relationship between the performance in
the OSCE and clinical experience.
Good performance in the OSCE examination was
signi®cantly associated with a learning style character-
ized by a desire to achieve and well-organized study
methods, but, somewhat to our surprise, not with
learning for meaning nor, negatively, with surface
learning.
What, then, of clinical experience? It has been
assumed by many that more is always better. The `best'
students are often the ones with greater than average
clinical experience ± a fact borne out in this study by the
powerful associations between positive learning styles
and clinical experience. But, as Samuel Johnson
pointed out in 1734, `it is incident to physicians, I am
afraid, beyond all other men, to mistake subsequence
for consequence' and we must look beyond simple
volume5 to the characteristics of our students and the
clinical exposure itself to maximize the educational
bene®ts. We were unable to demonstrate any direct
relationship between clinical experience and student
performance in the OSCE. However there was a rela-
tionship between learning style and clinical experience;
students whose preferred style was characterized by a
greater achieving or meaning orientation reported
signi®cantly greater clinical experience. Given the
similarity of our results in this area with those of
McManus,6 we believe that this relationship between a
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· I G Martin et al. 533
positive learning style and increased clinical experience
is both real and important. Although somewhat
speculative, it appears that students with an achieving
or meaning orientation both sought out more clinical
cases and perhaps made more of these in terms of
their own personal development. Extrapolating
somewhat, it seems that there is a relationship
between the three components of the study, OSCE
performance, learning style and clinical experience,
which with a degree of mathematical licence could be
expressed as:
OSCE performance µ Learning style µ Clinical
experience
An undergraduate medical student should not only be
skilled in the techniques of clinical medicine and
possess a suitable level of underpinning knowledge, but
also have the ability to continue to develop and learn
throughout their career; in short, to be a `critical
thinker'.11 The assessments that are used should re¯ect
the sort of graduate we wish to produce. The OSCE is
perceived by the students as a valid and fair test of
ability and the internal reliability of our OSCE was
good. Surface learning did not enhance OSCE perfor-
mance, relevant when the evidence is that medical
education has tended to encourage this style of
learning.8,9 The OSCE examination we currently run at
the end of the ®rst clinical year certainly has resulted in
a focusing of the students upon the importance of
clinical skills, but perhaps still falls short in assessing
the integrative processes of the `expert' physician;
perhaps an unfair criticism given the context in which
the OSCE was being used.
The ®nding that the female students performed
better in the OSCE examination, scoring on average
2á2% higher than their male colleagues, raises some
interesting questions. Much of this difference came
from the history stations and, while it may be that the
female students are more con®dent and ¯uent in
interviewing patients, we must ensure that the exami-
nation techniques used do not produce inadvertent
inequalities.
We need to ensure for the future that students are
encouraged to develop the positive and bene®cial styles
of learning which seem to be of importance in ensuring
that they gain the most from clinical experience and as
educators we need to assess, far more critically than
previously, exactly which aspects of clinical exposure
and teaching are truly of bene®t to our students. How
this can be achieved is challenging both to students and
teachers. There is little doubt that feedback from
teachers to students is important in improving the value
534 Clinical experience and performance in an undergraduate OSCE
of clinical experience.5 Structure and guidance in the
way students utilize clinical opportunities must be given
as much consideration as the volume of experience
provided, but more work is required to understand
better the complex relationship between clinical expo-
sure and student development.
References
1 Entwhistle NJ. Styles of Learning and Teaching: An Inte-
grated Outline of Educational Psychology for Students.
Teachers and Lecturers. New York: John Wiley & Sons, 1981.
2 General Medical Council. Tomorrow's Doctors. London:
GMC, 1994.
3 Schon DA. Educating the re¯ective practitioner: Towards a new
design for teaching and learning in the professions. San Francisco:
Jossey-Bass, 1987.
4 Jolly BC, Jones A, Dacre JE, Elzubeir M, Kopelman P, Hit-
man G. Relationship between students clinical experiences in
introductory clinical courses and their performance on an
objective structured clinical examination (OSCE). Acad Med
1996;71:909±16.
5 Chatenay M, Maguire T, Skakun E, Chang G, Cook D,
Warnock GL. Does volume of clinical experience affect per-
Ó Blackwell Science Ltd ME D I C A L ED U C A T I ON 2000;34:530±534
· I G Martin et al.
formance of clinical clerks on surgery exit examinations. Am J
Surgery 1996;172:366±72.
6 McManus IC, Richards P, Winder BC, Sproston KA. Clinical
experience, performance in ®nal examinations, and learning
style in medical students: prospective study. BMJ 1998;316
(7128):345±50.
7 Newble D, Swanson D. Psychometric characteristics of the
objective structured clinical examination. Med Educ
1988;22:325±34.
8 Coles CR. Differences between conventional and problem-
based curricula in their students' approaches to studying. Med
Educ 1985;19(4):308±9.
9 Martenson DF. Students' approaches to studying in four
medical schools. Med Educ 1986;20(6):532±4.
10 Swanson DB, Norman GR, Linn RL. Performance based as-
sessment: lessons from the health professions. Educational
Researcher 1995;24:5±11.
11 American Philosophical Association. Critical Thinking: A state-
ment of expert consensus for purposes of educational assessment and
instruction. Washington DC: US Department of Education,
Of®ce of Educational Research and Improvement; Report no.
ED 315423.
Received 14 December 1998; editorial comments to authors 11 February
1999; accepted for publication 22 March 1999