In this study, we found medical students under the 7-year curriculum performed better in OSCE than their 6-year curriculum counterparts at the beginning of the internship. After the clinical internship training at Taipei VGH, there was no difference in national OSCE scores between the 6- and 7-year curricula graduates.

There is a paucity of controlled studies comparing the outcomes between different medical school curriculum lengths [9]. Therefore, the long-term experience of medical curriculum reform in Canada provides us with a useful window to observe its impact on physicians’ performance and competency. In Canada, there has continued 3-year programs at both the University of Calgary and McMaster University since the 1970s. By using questionnaire scores from colleagues and patients, a 30-year long-term observation in Alberta showed that physicians of 3-year programs (from the University of Calgary) do not seem to be less competent than those who graduate from 4-year programs [25]. The present study findings are similar to those of Canada; that is, a shorter medical school curriculum seems to not interfere with the development of students’ clinical competence. Recently, some medical schools in the United States with 3-year MD programs introduced UME-GME continuum programs at their own institutions to strengthen the clinical competency of residents with a shorter curriculum [1]. In the present study, we found that students who received a clerkship at the same institution had a trend of better OSCE performance, suggesting that continuum programs can help accelerate clinical competencies. One reason for the better OSCEs performance in those who received ‘continuum programs’ (clinical clerkship and sub-internship at our institution) includes the ‘home advantage.’ This subgroup of trainees had built up their competencies of ‘system-based practice’ during their clerkship and could spend more time acquiring other clinical competencies in their sub-internship. Also, features of our curricular design for clinical clerkship could be another explanation. Our clinical clerkship compromised 80 important competencies with the well-designed training program. Trainees could receive clinical training in several departments, including 3-month internal medicine, 3-month surgery, 1.5-month OBS-GYN, 1.5-month pediatrics, 1-month neurology and psychiatry, 0.5-month orthopedics, and 0.5-month geriatrics. The diverse learning scenario ensures trainees have more experience in dealing with the different clinical situations.

The strength of the present study is that we used standardized OSCEs as outcome measurements. This OSCE protocol has been integrated into the national medical examination in Taiwan, which is a more objective measurement for the educational outcome [26]. Another strength is that the present study further analyzed the performance in serial OSCEs, thus providing a more comprehensive and longitudinal viewpoint for internship training. According to our research findings, medical students under a shorter curriculum have lower OSCE scores at the beginning of their internship, but there is no difference between 6- and 7-year curricula outcomes after the internship training. There are four possible explanations for these findings. First, the clinical teachers had information about students under different curriculum lengths. Therefore, clinical teachers may devote more effort to students in a shorter curriculum. Also, our institution organized a task force to strengthen the development of clinical competencies for trainees under the shortened curriculum. Strategies such as specialized mini-lectures, ongoing supportive supervision, and clinical mentorship have been implanted, which may contribute to the ‘catch-up’ of sub-interns under a 6-year-curriculum. Second, we introduced the competency-based medical education (CBME) framework simultaneously with the curricular reform. Under the new curriculum, undergraduates had been informed about the required competencies after completing their training a priori starting their sub-internship at our institution. Also, we redesigned our electronic assessment system and introduced a CBME-based evaluation framework for trainees under the new 6-year-curriculum. Hence, the length of the curriculum is no longer the key factor for educational outcomes [27]. Third, the lack of growth in the 7-year curricula graduates may be due to the ceiling effect; that is, most students achieved the goal of clinical sub-internship training. The measurement of advanced competencies for real-world practice is beyond the scope of OSCEs, which may require direct observation in the clinical setting. Fourth, our study found inferior performance in the initial mock-OSCE from those under the 6-year curriculum. The shortening lectures for clinical medicine before entering sub-internship may be the reason for inferior performance in the 1st mock-OSCE (at the beginning of sub-internship) from those under the 6-year curriculum. Moreover, our findings show that the clinical setting is the best strategy for efficient learning, which echoes the philosophy behind the curriculum reforms, that is, John Dewey’s “learning-by-doing theory.”

One critical issue that should be addressed is the decline of the 2nd OSCE shown in Table 2. The reasons underlying this decline might be due to learning fatigue or distraction. The distraction could be attributed to sub-interns focusing on applying for post-graduate training programs simultaneously as 2nd OSCE. The present study provides us a critical chance to improve the curricula design to prevent learning fatigue and distraction. Also, our study had several limitations. First, the present study was not controlled, and several possible confounding factors may have interfered with our results. For example, clinical teachers and institutions may change their teaching strategies after implementing a 6-year curriculum. Since it is nearly impossible to conduct a randomized controlled study to compare the outcomes of different curriculum lengths, the curriculum reform in Taiwan can provide us with an opportunity to analyze the association between curriculum length and clinical competency. Second, the study did not control for underlying school performance before entering the sub-internship. In Taiwan, medical students do not provide their grade reports to their sub-internship hospitals, and medical students from different medical schools may have different standards for academic grading. However, as every sub-intern in our institution took the mock OSCE-1 at the beginning of their sub-internship their initial scores could provide a standardized measurement for their educational outcome before entering the clinical sub-internship. Third, there are differences between the percentage of certain medical schools between trainees under 6- and 7-year-curriculum. The differences between the percentage of several medical schools were due to the increased capacity of certain university hospitals. Thus, their students can receive their sub-internship at their own university hospital. This is the reason for the decreased proportion of some medical schools between 6- and 7-year-curriculum. Fourth, the pass rate of national OSCEs is generally higher in our institution than the national average pass rate (Table 4) [28]. Therefore, caution should be taken to generalize our results into trainee at different institutions. Further studies using the national cohort is needed to portray the landscape of impacts after curricula reform in Taiwan.

Table 4 The OSCE pass rate of our institution and national average of Taiwan

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