Subbing in: Associations Between Screen-Based Clinical Substitutions and Pediatric Clerkship Performance Outcomes

Clinical experiences foster medical students’ clinical reasoning and professional identity. When real patient encounters are not available, students often utilize screen-based simulation. While screen-based substitutions can be a comparable alternative (Meyer et al. Acad Psychiatry 47:181-186, 2023; Patel et al. Cureus 16:e54541, 2024), there is less clarity regarding frequency and type of experiences students substitute with simulation and how this relates to clinical competencies. This retrospective study seeks to quantify the trends of screen-based substitutions among pediatric clerkship students and investigate associations between substitutions and performance outcomes. Data were collected from the Uniformed Services University, Department of Pediatrics archival records (2018–2023) of students (N = 884) tracked clinical experiences, scores on the National Board of Medical Examiners ® (NBME) Pediatrics Subject exam, and a written History and Physical (H&P) exam. Analysis included descriptive statistics of clinical substitutions by type, location, and over time. Regression analysis compared the number of substitutions and performance outcomes. Students substituted a mean of 0.79 (SD = 1.08) out of the 12 required clinical experiences. Acute Gastroenteritis was consistently and frequently substituted. Overall, substitutions increased significantly in 2020 compared to 2018 and 2019. There was a small but significant negative relationship between number of substitutions and NBME scores (β = -.06, p < .05), but no significant relationship with H&P scores (β = .02, p = .40). Increased use of substitutions since 2020 raises concerns about limitations in students' exposure to core clinical experiences. However, the minimal association between substitutions and performance outcomes suggests screen-based substitutions are still a reasonable alternative.