Assessment of clinical competence of graduating medical students and associated factors in Ethiopia

Abstract

Background
Ethiopia has scaled up medical education to improve access to healthcare which presented challenges to maintaining training quality. We conducted a study to assess the clinical competence of graduating medical students and the associated factors.

Methods and materials
A pretest assessment of a quasi-experimental study was conducted in 10 medical schools with a sample size of 240 students. We randomly selected 24 students per school. Clinical competence was assessed in a 12-station objective structured clinical examination. The clinical learning environment (CLE), simulation training, and practice exposure were self-rated. Mean scores for clinical competence, and satisfaction in the CLE and simulation training were calculated. Proportions of students with practice exposure, and who agreed on CLE and simulation items were done. Independent t-tests were used to look at competence differences among subgroups. Bivariate and multiple linear regression models were fitted for the outcome variable: competence score. A 95% statistical confidence interval and p-value < 0.05 were used for making statistical decisions. A 75% cut-off score was used to compare competence scores.

Results
Graduating medical students had a mean competence score of 72%. Low scores were reported in performing manual vacuum aspiration (62%), lumbar puncture (64%), and managing childbirth (66%). Female students (73%) had a significantly higher competence score than males (70%). Higher cumulative grade point average (CGPA), positive appraisal of the CLE, and conducting more clinical procedures were associated with greater competence scores. Nearly half of the students were not satisfied with the clinical practice particularly due to the large student number and issues affecting the performance assessment. About two-thirds of the students were not satisfied with the sufficiency of models and equipment, and the quality of feedback during simulation training. Nearly one-third of the students never performed lumbar puncture, manual vacuum aspiration, and venipuncture.

Conclusions
Medical students had suboptimal clinical competence. A better clinical learning environment, higher cumulative GPA, and more practice exposure are associated with higher scores. There is a need to improve student clinical practice and simulation training. Strengthening school accreditation and graduates’ licensing examinations is also a way forward.

Full text

Dejeneetal. BMC Medical Education (2024) 24:17
https://doi.org/10.1186/s12909-023-04939-1
RESEARCH
Assessment ofclinical competence
ofgraduating medical students andassociated
factors inEthiopia
Daniel Dejene1,2*, Firew Ayalew2, Tegbar Yigzaw2, Alemseged Woretaw2, Marco Versluis1 and
Jelle Stekelenburg1
Abstract
Background Ethiopia has scaled up medical education to improve access to healthcare which presented challenges
to maintaining training quality. We conducted a study to assess the clinical competence of graduating medical stu-
dents and the associated factors.
Methods andmaterials A pretest assessment of a quasi-experimental study was conducted in 10 medical schools
with a sample size of 240 students. We randomly selected 24 students per school. Clinical competence was assessed
in a 12-station objective structured clinical examination. The clinical learning environment (CLE), simulation training,
and practice exposure were self-rated. Mean scores for clinical competence, and satisfaction in the CLE and simula-
tion training were calculated. Proportions of students with practice exposure, and who agreed on CLE and simulation
items were done. Independent t-tests were used to look at competence differences among subgroups. Bivariate
and multiple linear regression models were fitted for the outcome variable: competence score. A 95% statistical confi-
dence interval and p-value < 0.05 were used for making statistical decisions. A 75% cut-off score was used to compare
competence scores.
Results Graduating medical students had a mean competence score of 72%. Low scores were reported in perform-
ing manual vacuum aspiration (62%), lumbar puncture (64%), and managing childbirth (66%). Female students (73%)
had a significantly higher competence score than males (70%). Higher cumulative grade point average (CGPA), posi-
tive appraisal of the CLE, and conducting more clinical procedures were associated with greater competence scores.
Nearly half of the students were not satisfied with the clinical practice particularly due to the large student number
and issues affecting the performance assessment. About two-thirds of the students were not satisfied with the suf-
ficiency of models and equipment, and the quality of feedback during simulation training. Nearly one-third of the stu-
dents never performed lumbar puncture, manual vacuum aspiration, and venipuncture.
Conclusions Medical students had suboptimal clinical competence. A better clinical learning environment, higher
cumulative GPA, and more practice exposure are associated with higher scores. There is a need to improve student
clinical practice and simulation training. Strengthening school accreditation and graduates’ licensing examinations
is also a way forward.
Keywords Graduating medical students, Clinical competence, Ethiopia
Open Access
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BMC Medical Education
*Correspondence:
Daniel Dejene
d.j.birhanu@umcg.nl; Daniel.Dejene@jhpiego.org
Full list of author information is available at the end of the article
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Dejeneetal. BMC Medical Education (2024) 24:17
Background
Many countries across the world have serious health
workforce challenges [1]. In 2020, a global shortage of
15.4 million health workers with huge skill mix imbal-
ances and maldistributions was reported [2]. Sub-
Saharan Africa (SSA) is disproportionally affected, with
relatively few health workers and a high burden of dis-
ease [3, 4]. e density of physicians in SSA countries
(< 0.3/1000 population in 2018) was very low as com-
pared to the high-income countries (2.0–5.0) [5, 6].
Like many African countries, Ethiopia invested to
increase the number of healthcare workers. It has been
implementing the national human resources for health
strategic plan which set a goal of increasing the stock of
physicians by five-fold from 5411 in 2016 to 28,121 in
2025 [7]. As a result, medical schools have been expanded
from 5 in 2005 to 43 in 2022, including 10 private col-
leges [8]. e annual number of graduates has increased
tenfold and reached 1500 – 1600. Despite the positive
strides, addressing the health workforce challenges in the
country is far from finished. For instance, the density of
physicians was still low, at 0.1 per 1000 people [9].
Increasing the number of training institutions can only
improve population health when the quality of training
is ensured. Workforce quality is an important part of the
solutions to the global human resource crisis. Enrolment
of so many students with limited medical school adapta-
tions has fueled the quality issues in the country [10–12].
Despite the commendable efforts in expanding medical
education, Ethiopia has lagged behind the WHO’s rec-
ommendations in reforming and implementing medical
curricula, expanding student clinical sites and simula-
tion-based training, and strengthening accreditation [13].
ere have been shortages of learning resources and
experienced faculty [14, 15]. With the rapid expansion,
the training quality concerns have further deepened
which might have affected student learning. Practice
analysis of Junior physicians also reported substantial
clinical skill gaps [16].
e effect of the training quality gaps on the compe-
tence of medical students is not well studied. erefore,
we conducted a study to assess the clinical competence of
graduating medical students and associated factors.
Methods andmaterials
Study design andperiod
is pretest assessment is part of a quasi-experimental
study aiming to assess the impact of project interventions
in improving the quality of medical education in Ethio-
pia. Considering the complexity of the medical education
environment for a random control study, we used a quasi-
experimental design which is well suited to examine the
cause-and-effect relationships among variables [17].
A posttest part of this quasi-experimental study will be
repeated in 2025. Changes in the clinical competence and
the associated factors from the pretest level will be used
as evaluation measures. is pretest study was carried
out in July and August 2022.
Study setting andstudy population
ere were 43 medical schools in Ethiopia, including
33 public and 10 private schools. Most medical schools
admit high school graduates using a direct entry scheme
while some accept graduates in the health and other sci-
ence fields using a graduate entry scheme. e duration
of medical education is 6 academic years, including 1
year of internship at the end. Starting from the third aca-
demic year, medical education is provided at hospitals
and other clinical settings. e study population for this
study was the 1556 undergraduate medical students who
completed or were nearly completing their internship
program and expected to graduate in 2022.
Sample size andselection criteria
Ten schools that had graduating classes around the same
period were selected in consultation with the Ethio-
pian Medical Association and the Ministry of Health.
Of the 10 selected schools, four employed graduate
entry schemes, and two were private schools. About 875
medical students were expected to graduate from the 10
schools in 2022. To determine the sample size, we con-
sidered a 95% confidence level, 80% statistical power, 1:1
optimal allocation (sample ratio of intervention to com-
parison), a moderate effect size of 0.5, and a design effect
of two. We calculated the minimum sample size of 218
graduating students. After including a non-response rate
of 10%, the final sample size was found to be 240.
Sampling procedures
To include 240 students from the 10 medical schools, we
considered recruiting 24 students per school. Because
our study aimed at observing students’ competence using
a 12-station objective structured clinical examination
(OSCE), including 24 students ensured better compe-
tency observations and the attainment of adequate data
points at each school. To develop the sampling frame, we
requested the lists of graduating medical students from
the deans’ offices. Using a lottery method, we randomly
selected 24 students. We provided the lists of students
to the assessors (data collectors) who invited students to
participate in the study. If the selected students were not
willing to participate for any reason, the data collectors
thanked them and did not replace them.
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Dejeneetal. BMC Medical Education (2024) 24:17
Measurements andinstruments
e key variables of interest were clinical competence,
clinical learning environment (CLE), simulation training,
and practice exposure. We assessed clinical competence
using a 12-station OSCE, a reliable method to assess clin-
ical skills [18, 19]. Using global and national standards,
OSCE case scenarios, assessment rubrics, and asses-
sor instructions were developed [20–22]. e stations
focused on the core competencies required for the provi-
sion of safe medical care which included 10 manned sta-
tions: taking a focused history, conducting pericardium
examination, providing patient education and counseling
for diabetes mellitus, conducting Leopold’s maneuver,
conducting manual vacuum aspiration (MVA) for incom-
plete abortion, managing childbirth, performing wound
suturing, taking emergency response for polytrauma,
obtaining consent for hernia repair, and performing
lumber puncture (LP). e remaining two stations were
unmanned and focused on interpreting chest X-rays and
complete blood cell counts for tuberculosis (TB) patients;
and prescribing medication for a malaria case. To ensure
content validity, we reviewed the stations with both sub-
ject matter experts and medical educators. e assess-
ment rubrics had 4 to 7 items and followed a five-point
global rating scale (GRS), where 1 meant “poor perfor-
mance”, 2 “unsatisfactory performance”, 3 “satisfactory
performance but not good”, 4 “good performance”, and
5 “excellent performance”. To assess the clinical learning
environment, we used a validated clinical learning evalu-
ation questionnaire (CLEQ) [23], a tool for measuring a
learning climate in the clinical settings for undergradu-
ate medical students with 18 items organized in four
domains: clinical cases, motivation of students, supervi-
sion by preceptors, and clinical encounter organization.
Similarly, we developed another 10-item structured tool
to assess the quality of simulation training using guide-
lines and literature [24, 25]. Students self-assessed their
experiences on each item of the two questionnaires on
5 points Likert scale, where 1 meant strongly disagree, 2
disagree, 3 neutral, 4 agree, and 5 strongly agree. In addi-
tion, we developed a structured tool to determine the
practice exposure of students to 12 task procedures in the
past 12 months. e list of procedures was adopted from
the national scope of practice and training curricula.
ere were also variables about the background charac-
teristics of medical students.
Data collection
e OSCE was administered by 18 physicians and medi-
cal educators. A two-day training was given to assessors
on data collection procedures, tools, ethical principles,
data quality assurance, and the CommCare software
application. Assessors informed study participants about
the purpose, procedure, and ethical principles of the
study and obtained consent. Study participants com-
pleted the CLEQ, simulation training quality, and prac-
tice exposure questionnaires. e study participants
were encouraged to provide accurate information and/or
the best plausible response to each item. For the OSCE
stations, the data collectors made sure that all essential
logistics (standardized patients, models, medical equip-
ment, medical supplies, assessor instructions, and assess-
ment rubrics) were available. e data collectors asked
the study participants to undertake the required tasks at
each OSCE station within 12 minutes. ey conducted
direct observations of students’ performance and rated
them exclusively using the GRS. e data collectors were
also closely supported by 6 supervisors to check errors
and omissions. e OSCE assessment rubrics had a total
of 64 items and an average Cronbach’s alpha value of 0.79
with a range of 0.62–0. 89 (Table2).
Data management andanalysis
We exported the data from CommCare v. 2.53 to SPSS
v. 27 for data cleaning and statistical analyses. Summary
statistics were computed for all key variables to check
outliers and missing data. Cronbach alpha coefficients
were computed to assess the consistencies of items listed
in each competence. Means, medians, standard devia-
tions, proportions, tables, and graphs were computed.
Mean scores for the 12 competencies and the overall
composite mean score were computed. Mean satisfac-
tion scores on CLE and simulation training were also
calculated. To conduct desired statistical tests using
continuous quantitative variables, we decided to merge
many items of CLE and simulation into a single one by
transforming the Likert scale data into composite mean
scores [26]. e five-point Likert scale measures of CLE
and simulation training were also grouped into two cat-
egories (strongly agree and agree as “agree”, and strongly
disagree, disagree and neutral as” disagree”), and propor-
tions were conducted to give a meaningful interpreta-
tion. Proportions were calculated for practice exposure.
Since the curriculum did not specify thresholds for the
number of clinical procedures expected to be performed,
the median for each procedure was used as a cutoff point
to decide between high and low exposures. e median
values were used as measures of central tendency since
the data had outlier values. An independent sample t-test
was used to make comparisons between male and female
students, private and public schools, direct and graduate
entries, students with high and low clinical exposures,
and students with high and low CGPA. We also checked
the necessary assumptions for regression analysis and
ensured the model’s adequacy [27]. Bivariate and multiple
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Dejeneetal. BMC Medical Education (2024) 24:17
linear regression models were then fitted. e outcome
variable was the competence score. e independent var-
iables were age, sex, school type, cumulative grade point
average (CGPA), school entry scheme, composite satis-
faction scores for the four CLE domains, and simulation
training. We considered all independent variables with
P < 0.025 at the bivariate level for inclusion in the multi-
variable regression analysis. A 95% statistical confidence
interval and p-value < 0.05 were used for making statisti-
cal significance decisions. Students are expected to mas-
ter essential skills for safe and beginner-level healthcare
delivery at the point of graduation. A 75% cut-off score
which is recommended in mastery learning was used in
comparing the competence scores [28].
Data quality assurance
We adopted a standardized CLEQ data collection tool to
assess the clinical learning environment. In the case of no
standardized tools, the questionnaires for OSCE, simula-
tion training, and practice exposure were reviewed and
validated by medical education experts. We recruited
senior medical education experts who have experience
in conducting OSCE as data collectors. A two-day train-
ing was provided to data collectors to standardize data
collection. Study investigators along with supervisors
ensured that quality data were collected. We used an
electronic data collection application to prevent data
entry errors and supervised the data collection process.
Ethics
Ethical approval for the study was obtained from the
Ethiopian Public Health Association and Johns Hopkins
Bloomberg School of Public Health Institutional Review
Board with IRB number 21116. Permission to conduct
the study was also obtained from the Ministry of Health
(MOH) and the deans of medical schools. Study par-
ticipants provided informed oral consent, and measures
were taken to protect autonomy and data confidentiality.
Results
Background characteristics
A total of 218 graduating medical students took part
in this study with a response rate of 90.8%. eir mean
age was 27.1 years. e majority of study participants
were males (70.2%), from public schools (86.2%), and
had a cumulative grade point average (CGPA) of more
than 3.00 at the beginning of the internship (74.5%).
Graduates from private medical schools were younger
(mean age 25.7 vs. 27.4 years), had higher proportions of
Table 1 Background characteristics of study participants (N = 218)
Characteristics Public school (N = 188) Private school (N = 30) Total (N = 218)
No % No % No %
Age in years
< 27 years 105 55.9 29 96.7 134 61.5
> =27 years 83 44.1 1 3.3 84 38.5
Mean age [SD] in years 27.4 [0.88] 25.4 [2.42] 27.1 [2.35]
The age range (in years) 25–37 25–28 25–37
Sex
Male 143 76.1 10 33.3 153 70.2
Female 45 23.9 20 66.7 65 29.8
Place of birth
Urban 127 67.6 28 93.3 155 71.1
Rural 59 31.4 2 6.7 63 28.9
Student entry scheme
Direct entry scheme 99 52.7 29 96.7 128 58.7
Graduate entry scheme 89 47.3 1 3.3 90 41.3
Medicine a rst career choice
Yes 175 93.1 28 93.3 203 93.1
No 13 6.9 2 6.7 15 6.9
CGPA at the start of the internship
> =3.50 44 23.4 13 43.3 57 26.1
3.00–3.49 93 49.5 13 43.3 106 48.6
< 3.00 51 27.1 4 13.3 55 25.2
Mean CGPA [range] 3.19 [2.4, 4.0] 3.33 [2.4, 3.8] 3.2 [2.4, 4.0]
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Dejeneetal. BMC Medical Education (2024) 24:17
female students (66.7% vs. 23.9%), and had higher CGPA
(3.33 vs. 3.19) than those from public medical schools
(Table1).
Competence scores ofgraduating medical students
e overall mean competence score of graduating medi-
cal students was 72%. e highest scores were observed
for obtaining consent for hernia repair (81%), and inter-
preting chest X-rays and CBC for TB patients (78%). On
the other hand, competence scores were relatively low
in conducting MVA for incomplete abortion (62%), per-
forming LP (64%), and managing childbirth (66%) (Fig.1).
ere was no statistically significant difference in over-
all student competence scores between public (71.6) and
private (71.7) schools. However, students from public
schools had significantly better scores in taking a focused
history (p = 0.001), conducting precordium examination
(p = 0.002), and obtaining consent for hernia patients
(p = < 0.001). On the other hand, students from private
medical had significantly better scores in patient educa-
tion and counseling (p = 0.03), prescribing medication for
a malaria case (p < =0.001), and wound suturing (p = 0.02)
(Table2).
Clinical learning environment
Medical students had an overall mean CLE satisfaction
score of 75.2%. e motivation of students during clinical
practicum had the highest score (83.7%). In addition, the
majority of the students knew their learning limitations
(91.7%), enjoyed learning at clinical practice sites (88.5%),
and thought that the supervisors were good role models
(89.9%). However, supervision of students during practi-
cum had a low score (71.4%). Significant of them also
reported that the way the supervisors dealt with medi-
cal students was satisfactory (40.8%), the number of stu-
dents in clinical sessions was appropriate (56.0%), and the
assessment of clinical learning was aligned with objec-
tives (53.7%) (Fig.2).
Simulation training quality
Overall, 51% of participants were satisfied with the qual-
ity of simulation training. Specifically, 77% of respondents
said the number of students at the skills development
lab (SDL) was appropriate, and 61% acknowledged that
supportive trainers were available. About two-thirds of
the respondents expressed dissatisfaction with the avail-
ability of models and equipment at the lab, and the feed-
back provided at each practice session, and did not enjoy
learning at the skills lab (Fig.3).
Clinical practice exposure
Of the 12 procedures assessed, the majority of students
performed the following tasks more than five times:
nutrition assessment (95.9%), urinary catheterization
Fig. 1 Mean clinical competece scores of graduating medical studetns in percentage
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Dejeneetal. BMC Medical Education (2024) 24:17
(94.5%), intravenous (IV) cannulation (93.1%), giving
oxygen (92.5%), and nasogastric (NG) tube insertion
(91.7%). On the contrary, significant proportions of
students never performed venipuncture (34.4%), lum-
bar puncture (LP) (30.7%), manual vacuum aspiration
(MVA) (30.3%), and assisted normal delivery (9.6%)
(Fig.4).
Factors aecting competence scores ofgraduating medical
students
Female medical students had 2.4% higher competence
scores compared to their male counterparts (p = 0.03).
On average. Medical students with a CGPA of < 3.00
had 7.1% lower competency scores compared to those
with a CGPA of > 3.50 (p = 0.001). Similarly, students
with a CGPA of 3.00–3.49 had on average 3.7% lower
Table 2 Mean competence scores of study participants in percentage by school type
The mean competence scores of the graduate entry students (72.3) and direct entry ones (71.2) had no signicant dierence. However, graduate entry students
scored higher in precordium examination (p < 0.001), conducting Leopold’s maneuver (p < 0.001), and obtaining consent for hernia repair (p = 0.004). On the other
hand, direct entry students performed better in tasks of patient education and counseling(p = 0.002) and lumbar puncture (p = 0.002) (Table3)
Skill station Number
of items Cronbach’s
alpha Public school
mean score,
(SD) a
Private school
mean score,
(SD) b
Mean score
dierence (c = a
- b)
p-value (t-test)
Focused history taking 5 0.78 69.2 (14.5) 56.8 (9.9) 12.4 < 0.001
Precordium examination 5 0.87 74.5 (16.5) 67.7 (9.5) 6.8 0.002
Interpreting chest x-ray & complete blood
count for TB case 4 0.64 78.6 (13.7) 75.3 (15.5) 3.2 0.235
Patient education & counseling for DM case 7 0.89 73.7 (14.1) 79.7 (11.4) −6.0 0.03
Prescribing medications for malaria case 4 0.62 71.2 (16.3) 85.0 (12.7) −13.8 < 0.001
Conduct Leopold’s maneuver 6 0.81 70.0 (17.1) 65.0 (12.7) 5.0 0.126
MVA for incomplete abortion 7 0.86 61.8 (17.8) 66.2 (12.1) −4.4 0.093
Managing childbirth 5 0.78 65.5 (16.0) 68.4 (17.4) −2.9 0.361
Wound suturing 5 0.86 74.0 (17.7) 80.0 (11.6) −6.0 0.020
Emergency response for a polytrauma 5 0.77 74.8 (13.6) 75.7 (15.5) −0.9 0.759
Obtaining consent for hernia repair 5 0.77 82.8 (16.3) 71.9 (10.5) 10.9 < 0.001
Performing LP 6 0.87 63.5 (20.4) 69.0 (9.3) −5.5 0.156
Composite mean score 64 0.79 71.6 (7.80 71.7 (4.8) −0.1 0.928
Table 3 Mean competence scores of study participants in percentage by medical school entry schemes
Female medical students (73.2%) had a signicantly higher competence score than their male counterparts (71.0%) (p = 0.04). Female students outperformed males
in four skill areas: interpreting chest X-rays and CBC for TB patients (p = 0.02), prescribing medication for malaria cases (p = 0.04), conduc ting MVA for incomplete
abortion (p = 0.02), and performing lumbar puncture (p = 0.01) (Table4)
Skill station Direct mean score,
(SD) a Graduate mean score,
(SD) b Mean score dierence
c = a- b p-value (t-test)
Focused history taking 66.8 (13.3) 68.6 (16.3 −1.8 0.380
Precordium examination 70.4 (15.2) 78.2 (15.8) −7.8 < 0.001
Interpreting chest x-ray and complete blood count
for TB case 79.8 (13.8) 75.8 (13.9) 4.0 0.040
Patient education & counseling for DM case 77.0 (13.20 71.0 (14.1) 6.0 0.002
Prescribing medications for malaria case 71.3(17.7) 75.7 (14.3) −4.4 0.040
Conduct Leopold’s maneuver 64.4 (15.5) 76.3 (15.6) −11.9 < 0.001
MVA for incomplete abortion 62.0 (17.1) 63.1 (17.3) −1.1 0.650
Managing childbirth 67.4 (15.2) 63.7 (17.3) 3.7 0.100
Wound suturing 73.1 (18.2) 77.3 (15.3) −4.2 0.070
Emergency response for a polytrauma 76.4 (14.4) 72.9 (12.8) 3.5 0.070
Obtaining consent for hernia repair 78.7 (16.2) 85.0 (15.1) −6.3 0.004
Performing LP 67.7 (18.0) 59.4 (20.3) 8.3 0.002
Composite mean score 71.2 (7.5) 72.3 (7.4) −1.1 0.317
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Dejeneetal. BMC Medical Education (2024) 24:17
Table 4 Mean competence scores of study participants in percentage by sex
Medical students with a CGPA of 3.25 or more (74.3%) had a signicantly higher competence score than those with a CGPA of 3.25 (69.5%) (p < 0.001). Those with
a CGPA of at least 3.25 also outperformed in six competence areas: performing precordium examination (p = 0.024), interpreting chest X-rays and complete blood
count for TB case (p = 0.006), conducting Leopold’s maneuver (p = 0.004), wound suturing (p < 0.001), emergency response for polytrauma (p = 0.006), and performing
lumbar puncture (p = 0.007) (Table5)
Skill station Male mean score
(SD) a Female mean score
(SD) b Mean score dierence
c = a-b p-value (t-test)
Focused history taking 67.7 (14.9) 66.9 (13.9) 0.8 0.690
Precordium examination 74.5 (15.9) 71.4 (15.8) 3.1 0.180
Interpreting chest x-ray and CBC for TB case 76.7 (14.0) 81.5 (13.3) −4.5 0.020
Patient education and counseling for DM case 72.6 (13.8) 79.0 (13.2) − 6.4 0.830
Prescribing medications for a case of malaria 72.9 (16.1) 73.5 (17.6) −0,6 0.040
Conduct Leopold’s maneuver 70.9 (16.8) 65.9 (15.8) 5.0 0.150
MVA for incomplete abortion 61.3 (17.4) 65.0 (16.5) −3.7 0.020
Managing childbirth 64.2 (16.4) 69.9 (15.0) −5.7 0.090
Wound suturing 73.5 (17.9) 77.9 (14.7) −4.4 0.120
Emergency response for a polytrauma 74.0 (13.9) 77.2 (13.6) −3.2 0.120
Obtaining consent for hernia repair 81.0 (17.0) 82.0 (13.6) −1.0 0.660
Performing LP 62.3 (20.3) 68.9 (16.1) −6.6 0.010
Composite mean score 71.0 (7.4) 73.2 (7.3) −2.2 0.040
Fig. 2 Percent of medical graduates who were satisfied with CLE items and satisfaction scores by CLE domain (N = 218)
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Page 8 of 13
Dejeneetal. BMC Medical Education (2024) 24:17
competency scores than those with a CGPA of > 3.50
(p = 0.001). For a unit increase in the satisfaction score of
students’ motivations in the CLE, the mean competence
score increased by 12.7% (p = 0.020) (Table6).
Discussion
After a successful primary healthcare expansion, Ethio-
pia has strengthened secondary and tertiary care aiming
to increase its responsiveness to the population’s health
needs. is progress has stimulated the rapid expansion
of medical training in the country. With no congruent
attention given to maintaining the training quality, the
expansion has affected the medical schools in meeting
the minimum pre-service education standards [28, 29].
Understanding the real effects of rapid training expansion
and the challenges it poses is a critical step for improve-
ment; particularly in contexts like Ethiopia where there is
scanty evidence. To that end, we conducted this research
to answer two main questions: what level of clinical com-
petence did the undergraduate medical students master
at the point of graduation? And which factors were asso-
ciated with competence development?
e results of this study showed that the graduating
medical students had suboptimal competence scores as
Table 5 Mean competence scores of study participants in percentage by cumulative GPA
Skill station CGPA < 3.25 mean
score, (SD) a CGPA > = 3.25 mean
score, (SD) b Mean score dierence
(c = a - b) p-value (t-test)
Focused history taking 66.9 (15.3) 68.2(13.7) −1.3 0.495
Precordium examination 71.4 (15.3) 76.3(16.1) − 4.9 0.024
Interpreting chest x-ray & complete blood count
for TB case 75.9(14.0) 81.0 (13.4) − 5.1 0.006
Patient education & counseling for DM case 73.3 (13.8) 76.0 (14.0) −2.7 0.144
Prescribing medications for malaria case 71.5 (17.3) 75.0(13.5) − 3.5 0.120
Conduct Leopold’s maneuver 66.4 (15.3) 72.9 (17.5) −6.5 0.004
MVA for incomplete abortion 60.6 (17.6) 64.6 (16.5) −4.0 0.082
Managing childbirth 64.5(15.8) 67.6(16.5) −3.1 0.173
Wound suturing 70.1(18.2) 80.5 (13.7) −10.4 < 0.001
Emergency response for a polytrauma 72.6 (14.1) 77.8(13.1) −5.1 0.006
Obtaining consent for hernia repair 79.6 (17.6) 83.4 (13.8) −3.4 0.076
Performing LP 61.1 (17.9) 68.1(19.9) −7.0 0.007
Composite mean score 69.5 (7.3) 74.3 (6.9) −4.8 < 0,001
Fig. 3 Percent of graduating medical students who were satisfied with the simulation training quality (N = 218)
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Page 9 of 13
Dejeneetal. BMC Medical Education (2024) 24:17
a whole and in many competence areas as compared to
the 75% cut-off score, signifying students’ capability gaps
required for essential healthcare delivery. e pervasive
shortages of experienced faculty and learning infrastruc-
ture, and challenging practical learning in Ethiopia’s
medical schools coupled with the underdeveloped medi-
cal education regulation practices might be the underly-
ing factors [7, 15, 30]. Comparable competence scores
were also reported by studies conducted in Ethiopia and
elsewhere [31–34]. Challenges of medical education due
to shortages of critical training inputs and processes were
similarly reported in Tanzania [35]. e competence gaps
among the study participants made it clear that the medi-
cal graduates were not fully prepared for the responsi-
bilities of general practitioners listed under the national
scope of practice guidelines [20]. is means that the new
graduates’ performance, confidence, professional iden-
tity, career progression, and quality of life can be affected
[36, 37]. is all can have huge implications for the stand-
ards of patient care.
Effective preservice education for medical students
requires high-quality clinical preceptorship and simu-
lation training [38]. Repeated practice opportunities in
clinical sites can boost the competencies learned and
experiences acquired [39–41]. To that end, ensuring
an optimal number and variety of cases in clinical set-
tings is vital [42]. However; as stipulated in this study,
performing hands-on clinical procedures by the medical
students proved relatively more difficult. And a signifi-
cant proportion of the students also had fewer practice
exposures. On top of that, our study depicted that the
medical students had challenging simulation and clini-
cal learning environments. Studies conducted in other
countries also discovered that the psychomotor abilities
of final-year medical students were not fully developed
[43–45]. e large number of enrolled students in Ethio-
pia’s medical schools might negatively affect the practical
training in both simulation and clinical settings. Intro-
ducing medical education program accreditation and
regulation has the potential to motivate schools to pur-
sue quality [46]. Other researchers also corroborated our
reports of the unnecessary effects of the rapid training
scale-up and overwhelming students in Ethiopia [10–12,
29, 30]. However, many of the study participants had
favorable perceptions regarding the number of students
during practice. is might trigger questions about how
well the schools used clinical rotations and scheduling
to offset practice site overcrowding. And did the schools
have adequate clinical sites used for student practice?
[47]As per the findings of our study, the medical stu-
dents’ motivation in clinical learning was associated with
competency development. Unfortunately, the existing
CLE gaps including the suboptimal availability of case
varieties, motivation and supervision of students, and
Fig. 4 Percent of graduating medical students who conducted 5 or more procedures and never conducted
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Page 10 of 13
Dejeneetal. BMC Medical Education (2024) 24:17
organization of clinical encounters affected the quality of
student practice which might diminish the competence
development [48–50].
Similar to what we reported, good academic perfor-
mances were also associated with competence attainment
in other studies [51]. is entails that medical schools
should ensure that well-prepared students are enrolled
and effectively taught, evaluated, and supported stu-
dents across all stages of the curriculum. Despite many
programmatic reports suggesting gender disparity in
Ethiopia disfavoring females [52], this study depicted that
female medical students had higher competence scores
than males. ey also had better scores in managing TB
and malaria cases, conducting manual vacuum aspiration
and lumbar puncture. Female nonphysician anesthesia
students in Ethiopia similarly outperformed their male
counterparts [53]. However, the male midwifery students
had a better performance than the females [54].
Strengths andweaknesses
Covering all the required clinical competency domains
and considering all types of medical schools found in the
country enabled us to generate high-quality evidence. We
conducted a direct observation of student performance
using OSCE tools which have acceptable reliabilities and
high objectivity. e multiple quality indicators were
evaluated in the causal chain of educational inputs, pro-
cesses, and outcomes, providing a better picture of the
training. To address logistical challenges, we widened the
data collection period to include all schools as the aca-
demic calendars of medical schools were variable. e
shortage of OSCE logistics was solved in collaboration
with the medical schools. Since we did not get standard-
ized assessment rubrics for our purpose, experts assisted
in developing and piloting rubrics based on the curricula
and standards.
Conclusions
Medical students had suboptimal clinical competence.
Lower competence scores were found in clinical proce-
dures. A better CLE, higher cumulative GPA and aca-
demic performance, and more practice exposure were
associated with high competence scores. We recommend
that medical schools need to expand student clinical sites
Table 6 Bivariable and multivariable linear regression results to assess factors affecting the competence of graduating medical
students
The mean competence scores of students who performed tasks of giving oxygen above the median of 30, IV cannulations above the median of 25, urinary
catheterization above the median of 20, and NG tube insertion above the median of 15 were signicantly larger than that of students with task performance
below the corresponding medians. (p < 0.031). Similarly, the mean competence scores of students who performed tasks of wound suturing more than the median
of 10, venipuncture more than the median of 10, and abdominal paracentesis more than the median of 6 were signicantly larger than that of students with task
performance below the corresponding medians (p < 0.011) ( Table7)
Independent variable Bivariable model Multivariable model
Unstandardized
coecient (B) 95% C.I. of B P-value Unstandardized
coecient (B) 95% C.I. of B P-value
School type
Public (ref)
Private −0.015 [− 0.056, 0.027] .48 – – –
Sex
Male (ref)
Female −.031 [−.062, 0] .05 0.024 [0.003, 0.045] .03
Age of student in years 0.014 [0.008, 0.019] <.001 −0.005 [− 0.013, 0.003] .19
Student entry scheme
Graduate (reference)
Direct −.074 [−.101, −.046] <.001 0.027 [−0.010, 0.064] .15
CG PA
> 3.50 (ref) – – – – – –
3–3.49 −0.004 [−0.024, 0.016] .69 −0.037 [− 0.059, − 0.015] .001
< 3.00 − 0.05 [− 0.072, − 0.028] <.001 −0.071 [− 0.098, − 0.045] <.001
Quality of simulation training 0.047 [−0.024, 0.117] .19 −0.001 [− 0.071, 0.069] .98
CLE Cases 0.492 [.418, .566] <.001 −0.052 [−0.129, 0.026] .19
CLE motivation 0.723 [0.636, .810] <.001 0.127 [0.018, 0.235] .02
CLE supervision 0.515 [.465, .566] <.001 0.042 [−0.030, 0.114] .25
CLE doctor-patient encounter 0.591 [.536, .647] <.001 0.002 [−0.079, 0.084] .95
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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Dejeneetal. BMC Medical Education (2024) 24:17
to primary healthcare units and private health facilities.
Effective scheduling and clinical rotations are required to
boost practice opportunities. Expanding and/or develop-
ing preceptors should be conducted. It is also imperative
to address the simulation training gaps. Strengthening
licensing examinations is also a way forward to ensure the
graduates are fit for practice. Research studies are needed
to understand the effects of the current medical educa-
tion status on patient outcomes. Additional investigation
is also required to assess the medical students’ ethics,
leadership, communication, and collaboration skills.
Abbreviations
CBC Complete blood count
CGPA Cumulative grade point average
CLE Clinical Learning Environment
CLEQ Clinical Learning Environment Questionnaire
CPD Continuing professional development
DM Diabetes mellites
GRS Global rating scale
IRB Institutional Review Board
IV Intravenous
LP Lumbar puncture
MOE Ministry of Education
MOH Ministry of Health
MVA Manual vacuum aspiration
NG tube Nasogastric tube
OSCE Objective structured clinical examination
SD Standard deviation
SDL Skills development laboratory
SOP Scope of practice
SSA Sub Sahara Africa
TB Tuberculosis
USAID United States Aids for International Development
WHO World Health Organization
Acknowledgements
We would like to acknowledge the study participants and data collectors for
their dedication and time in obtaining quality data. We also acknowledge
the following experts who contributed to conducting this study at various
stages. Samuel Mengistu (MD, MPH, Ph.D.) supported us in the designing and
planning of the study and data collection. Yohannes Molla (BSc, MSc, FMER)
Table 7 Mean competence difference of study participants by level of practice exposure (number of conducted procedures)
Conducted procedure Competency score Mean dierence 95% CI P-value
Nutrition assessment
< or = 47 0.7077
> 47 0.7253 −0.01767 −0.03748, 0.00214 0.08
Giving oxygen
< or = 30 0.6951
> 30 0.7343 −0.03917 − 0.05851, − 0.01981 < 0.001
Intravenous cannulation
< or = 25 0.7044
> 25 0.7267 −0.02225 −0.04234, − 0.00216 0.03
Urinary catheterization
< or = 20 0.6996
> 20 0.7313 −0.03171 − 0.05141, − 0.01202 0.002
Nasogastric insertion
< or = 15 0.6989
> 15 0.7304 −0.03152 − 0.05163, − 0.01141 0.002
Assist normal delivery
< or = 10 0.7083
> 10 0.7233 −0.01492 − 0.03526, 0.00542 0.07
Conduct wound suturing
< or = 10 0.7042
> 10 0.7279 −0.02362 −0.04354, − 0.00370 0.01
Venipuncture
< or = 10 0.7015
> 10 0.7296 −0.02809 −0.04783, − 0.00835 0.005
Bag and mask ventilation
< or = 6 0.7094
> 6 0.7235 −0.01413 −0.03399, 0.00573 0.162
Abdominal paracentesis
< or = 6 0.6991
> 6 0.7321 −0.03304 −0.05263, − 0.01345 < 0.001
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Page 12 of 13
Dejeneetal. BMC Medical Education (2024) 24:17
and Mintwab Gelagay (BSc, MSc FMER) contributed to conducting data col-
lection and logistic preparation for the study. Assegid Samuel (BSc, MSc.) and
Shelemo Shawula (MD, MPH) contributed to reviewing the study protocol,
interpretation of the results, and at the early stage of the write-up.
Authors’ contributions
Daniel Dejene, the lead author, contributed to the study concept and design,
statistical analysis, results interpretation, and drafting and revision of the
manuscript. Firew Ayalew, Tegbar Yigzaw and Alemseged Woretaw contrib-
uted to the study concept and design, results interpretation, and manuscript
revision.Marco Versluis and Jelle Stekelenburg contributed to the study
concept and design, drafting, and revision of the manuscript. All authors read
and approved the final version of the manuscript.
Authors’ information (optional)
DD (MD, MPH, FMER) is a Ph.D. student at the Department of Health Sciences,
Global Health, the University Medical Center at Groningen University. He is the
Deputy Chief of Party for the HWIP project supporting the quality of medical
education, Jhpiego Ethiopia. FA (MSc, Ph.D.) is the senior research advisor for
the HWIP project, Jhpiego Ethiopia. TY (MD, Ph.D., MPH, FMER) is the Chief
of Party for the HWIP project, Jhpiego Ethiopia. AW (MD, MSc) is a senior
Education and Training Advisor, at Jhpiego Ethiopia. MV (MD, Ph.D.) and JS are
professors at the Department of Health Sciences, Global Health, University
Medical Centre Groningen/University of Groningen.
Funding
This work was financially supported by Jhpiego Ethiopia under its USAID
Health Workforce Improvement Program (HWIP). Funding for open access is
not provided by the donor.
Availability of data and materials
The datasets used and/or analyzed during the current study are available from
the corresponding author upon reasonable request.
Declarations
Ethics approval and consent to participate
Ethical approval for the study was obtained from the Ethiopian Public Health
Association and Johns Hopkins Bloomberg School of Public Health Institu-
tional Review Board with IRB number 21116. Permission to conduct the study
was also obtained from the Ministry of Health (MOH) and the deans of training
institutions. Study participants provided informed oral consent, and measures
were taken to protect autonomy and data confidentiality. All collected data
were anonymized, handled, and stored by the tenets of the Declaration of
Helsinki.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Author details
1 Department of Health Sciences, Global Health, University Medical Centre Gro-
ningen/University of Groningen, Groningen, Netherlands. 2 Jhpiego Ethiopia,
P.O. Box:2881, code, 1250 Addis Ababa, Ethiopia.
Received: 23 March 2023 Accepted: 5 December 2023
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