Standardized patient (SP)-based clinical skills examinations (CSEs) have been widely used to assess the clinical performance of medical students or residents in the context of clinical education. Although SPs can skillfully simulate patients’ symptoms and signs in training sessions for intimate examination skills [1], we cannot allow examinees to perform intimate examinations as part of CSEs due to difficulties such as the presence of too many examinees in Korea [2], potential unsafety for the SPs, and inability of the SPs to simulate real pathologic signs in the pelvis. Thus, we have usually given written descriptions of intimate examination findings to examinees in the context of an SP encounter. This does not reflect the reality of clinical encounters (i.e., this method lacks authenticity), and it fails to assess students’ true competency in performing relaxed and patient-centered intimate examinations as part of patient encounters.

Intimate examinations, such as pelvic exams, should be assessed in an authentic way because that is the only way to assess students’ real ability to deal with gynecologic patients. According to the relevant literature, a few hybrid stations have been developed for technical skills assessment [3], but no study has been found on a hybrid CSE station simultaneously assessing history-taking, a physical examination including an intimate examination, and patient-physician interactions. In this context, we developed a hybrid SP station using SPs and gynecologic models of a Papanicolaou (Pap) test. We present our trial of hybrid CSE station implementation and an evaluation of the authenticity, acceptability, and feasibility of the hybrid SP-based gynecology CSE station. We hypothesized that the medical students would evaluate the hybrid station as being more authentic, acceptable, and feasible than the other SP encounter stations.

This is the first trial to be reported in the literature of a hybrid CSE combining an SP clinical encounter and a technical skills station. In standard gynecologic SP stations, students have to stop the interaction with the SP while reading a written description of the pelvic examination. The general technical skills assessment only assesses whether students perform the procedures of the Pap test accurately. However, in this study, we sought to assess students’ ability to perform the entire process of a gynecologic patient encounter, including an intimate examination without a written description.

Forsaking the standard gynecologic stations, where the SP gives a written description of the examination findings to students, we assessed students in a realistic clinical setting in which they performed a Pap test on a pelvic model. Most of the students and professors agreed that the hybrid station was more realistic and practical than the standard CSE, proving the authenticity of the hybrid station. Both real and simulated patient involvement have been found to show positive impacts on the assessment of intimate examination skills [1]. Therefore, we suggest that this hybrid station is a more useful and safer way to assess students’ pelvic examination skills.

Most of the medical students (63.9%) and professors (94.1%) agreed that the task was acceptable as a way to assess the students’ competence. The average score of the hybrid station was similar to those of the other 5 SP stations, further suggesting that this hybrid station was acceptable for assessing the students’ clinical reasoning and communication skills at the same time.

Three-fourths of the medical students and most of the professors agreed that the tasks were feasible after reading the instructions for the hybrid station, and more than half of the students and three-fourths of the professors agreed that a proper amount of time was allotted for the hybrid station. The fact that the average score of the hybrid station was similar to those of other stations also supports the conclusion that this 15-minute hybrid station was an acceptable tool for assessing students’ performance.

We set up this station to realistically simulate outpatient gynecology clinics, and students could see the pelvic model when they entered the room. Therefore, all students tried to perform the Pap test, which may have tended to increase their total scores at the hybrid station, although 64.7% of the students felt that the hybrid station was more difficult than the other SP encounter stations. Students have been found to be nervous in the presence of SPs, leading to lower scores on pelvic exams [4]. A more detailed and well-articulated scenario, as well as variations in the station setup, space, and checklist, should be developed to assess whether students make different diagnoses and perform different tests for different patients when similar test items are present in the exams. Various hybrid stations should be developed that will be helpful for assessing medical students’ communication skills, ethics, and technical skills. Further investigations should focus on the impact of hybrid stations on students’ attitudes towards various responses of the SPs.

The limitations of the present study are as follows: the retrospective cross-sectional observational design, and the use of only 1 hybrid station as the comparison group. Nevertheless, we found that using an SP combined with a simple skills test was an authentic, acceptable, and feasible way of assessing students’ performance of both technical skills and clinical reasoning skills.

In conclusion, our results satisfied the hypothesis that medical students would evaluate the hybrid station as being more authentic, acceptable, and feasible than the other SP encounter stations. Therefore, we suggest that hybrid exams are a useful tool for assessing students’ performance, including clinical reasoning ability.