(2023) 23:859
Murakami et al. BMC Medical Education
https://doi.org/10.1186/s12909-023-04798-w

BMC Medical Education

Open Access

RESEARCH

The effectiveness of simulation-based
education combined with peer-assisted
learning on clinical performance of first-year
medical residents: a case-control study
Taku Murakami1, Akira Yamamoto2, Hideharu Hagiya1*, Mikako Obika1, Yasuhiro Mandai3, Tomoko Miyoshi1,
Hitomi Kataoka4 and Fumio Otsuka1

Abstract
Background Simulation-based education and peer-assisted learning (PAL) are both known as useful educational
methods. Previous research has reported that combining these two methods are effective for training medical residents in short-term evaluation. This study was aimed to evaluate the middle- to long-term effects of simulation-based
education combined with PAL on the performance of medical residents during emergency department duties.
Methods This study was designed as a case-control study and conducted over three years at Okayama University Hospital in Japan. Postgraduate-year-one medical residents were assigned to three groups: a simulation groupthat received simulation-based education, a lecture group that received traditional lecture-based education,
and a control group that received no such prior trainings. Prior training in emergency department duties using PAL
was performed as an educational intervention for the simulation and lecture groups during the clinical orientation
period. The residents’ medical knowledge was assessed by written examinations before and after the orientation. The
performance of residents during their emergency department duties was assessed by self-evaluation questionnaires
and objective-assessment checklists, following up with the residents for three months after the orientation period
and collecting data on their 1st, 2nd, and 3rd emergency department duties. All the datasets collected were statistically analyzed and compared by their mean values among the three groups.
Results A total of 75 residents were included in the comparative study: 27 in the simulation group, 24 in the lecture group, and 24 in the control group. The simulation and lecture groups obtained significantly higher written
examination scores than the control group. From the self-evaluation questionnaires, the simulation group reported
significantly higher satisfaction in their prior training than the lecture group. No significant differences were foundin the emergency department performance of the residents among the three groups. However, when evaluating
the improvement rate of performance over time, all three groups showed improvement in the subjective evaluation,and only the simulation and lecture groups showed improvement in the objective evaluation.

*Correspondence:
Hideharu Hagiya
hagiya@okayama-u.ac.jp
Full list of author information is available at the end of the article© The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to theoriginal author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images orother third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line
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regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of thislicence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Murakami et al. BMC Medical Education(2023) 23:859

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Conclusion Simulation-based education combined with PAL is effective in improving the knowledge and satisfaction of medical residents, suggesting the possibility of improving work performance during their emergency department duties.
Keywords Medical Education, Educational Measurement, Simulation Training, Peer Group, Emergency Medicine,Internship and residency, Curriculum, Personal satisfaction, Case-control studies

Background
Simulation-based education is a highly effective method
for the acquisition of new skills [1–3]. Specifically, in thefield of emergency medicine, numerous studies have confirmed the effectiveness of simulation-based educationin providing learners with a safe training environment[4, 5]. Peer-assisted learning (PAL) is another effective
approach for training young doctors in clinical practices[6–8]. Our previous research has shown that the combination of simulation-based education and PAL yields
superior learning outcomes compared to traditional lecture-based education, as evidenced by short-term evaluations [7]. However, the medium- and long-term effectsof simulation-based education in clinical settings havenot been revealed [7]. As of October 2023, we searched
PubMed database for relevant keywords. Although there
are 7,671 results for studies with the keywords “simulation” and “emergency medicine” and 1,413 results forstudies with the keywords “peer-assisted learning”, only
18 studies contain all three keywords and no case-control
studies have been reported on simulation-based education combined with PAL as prior training for emergency
department duties. Revealing the educational outcomesof combining simulation-based education and PAL for
training medical residents can provide valuable insights
into the curriculum development for future medical
training programs. This study was designed as a casecontrol study to assess the effectiveness of integrating
simulation-based education and PAL as prior training forpostgraduate-year-one (PGY-I) medical residents in performing their emergency department duties.
Methods
This case-control study was conducted over three years
from 2016 to 2018, at Okayama University Hospital in
Japan, focusing on PGY-I medical residents. The PGY-I
residents were divided into three groups: a simulationgroup receiving simulation-based education as priortraining, a lecture group receiving traditional lecturebased education as prior training, and a control groupwith no prior training. The prior training was conductedduring the orientation period for PGY-I prior to theirclinical practice. The control group, which did not receive
any prior training but attended the orientation program,

was established to compare the impact of prior training
among the groups. In addition, the simulation and lecture groups were compared to evaluate the educational
methods of the prior training performed in each group.
All PGY-I residents were followed up until the end of
their two-year medical residency program to ascertain
the department they chose for their future specialties.
The eligibility criteria for participation required the submission of a consent form. Participants with a response
rate of less than 50% on the required questionnaires andchecklists were excluded due to insufficient data. The residents were divided into the three groups based on theorder of their names in the Japanese syllabary.
Our previous study performed by Yamamoto et al. [7]found that the combination of simulation-based education and PAL has a significantly positive effect on thelearning outcomes of medical residents in a short-term
evaluation. However, medium- and long-term evaluations of the learning effects of simulation-based education combined with PAL and its effects on actual clinicalpractices have not been fully investigated. In this study,
we analyzed the effects of prior trainings using simulation-based education and PAL on the emergency department duties of PGY-I residents. We utilized the PAL
method demonstrated in the previous study [7] where
postgraduate-year-two (PGY-II) residents taught PGY-I
residents and developed case studies for prior training
sessions. The case study scenarios were designed as emergency medicine cases and were supervised by specialized staff (Murakami, Yamamoto, and Mandai) trained
to provide simulation-based education at the Universityof Hawaii (John A. Bunrs School of Medicine, Sim Tiki
Simulation Center University). Three case study scenarios –acute myocardial infarction, multiple traumas, andaspiration pneumonia– were prepared as typical cases
encountered by medical residents in their emergency
department duties, and all case studies were evaluatedfor the level of difficulty, validity, accuracy, and effectiveness through actual simulation and lecture sessions
beforehand [7, 9, 10]. The duration of the prior training
for the simulation and lecture groups was adjusted to be
the same length in order to avoid any bias due to differences in study time. Prior clinical training for the simulation and lecture groups was performed in addition to theclinical orientation for all PGY-I residents to participate;Murakami et al. BMC Medical Education(2023) 23:859

for the control group, only clinical orientation was performed, and no prior training was performed. To avoid
potential bias, the assigned groups of each PGY-I resident
were not revealed to other participants, and the residents
were strictly prohibited from sharing any information acquired during prior training. All PGY-I residents
were given a questionnaire and a pre-test in the formof a written examination at the beginning of the clinical orientation period to ascertain their demographics
and academic performance. The simulation, lecture, andcontrol groups received simulation-based education asprior training, lecture-based education as prior training,
and no prior training, respectively. After the clinical orientation and educational interventions were completed,
all PGY-I residents were given another questionnaire anda post-test in the form of a written examination to reevaluate their academic performance (Fig. 1a). Questionnaire items of the written examinations were in common
in pre-test and post-test, being composed of 24 multiple
choice questions, four short-answer questions, and one
essay question. This was made up to evaluate the knowledge of emergency cases of acute myocardial infarction,
multiple traumas, and aspiration pneumonia.
The performance of PGY-I residents during their emergency department duties was evaluated by following
up with the residents for three months after the clinicalorientation period and collecting data on their 1st, 2nd,
and 3rd emergency department duties. To assess resident performance during emergency department duties,

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self-evaluation questionnaires were administrated to the
PGY-I residents to collect subjective data, and objectiveassessment checklists were provided to the PGY-II residents who worked with the relevant PGY-I residents tocollect objective data. The validity of questionnaires andchecklists for assessing trainee performance was reported
by Boynton et al. [11] and Artino et al. [12]. For our study,
each item of the self-evaluation questionnaire and objective-assessment checklist was rated on a 10-point scale.
The self-evaluation questionnaire included eight elements: medical history, assessment of the patient’s general condition, physical examination, laboratory testing,treatment, differential diagnosis, follow-up assessment,
and work stress level. Additionally, residents in the simulation and lecture groups were asked to rate the extent
to which they found their prior training during the orientation period useful for their emergency department
duties on a 10-point scale. The elements of the objectiveassessment checklist were designed to be the same as theeight elements of the self-evaluation questionnaire sothat the results could be easily compared. To avoid bias,
PGY-II residents who evaluated PGY-I residents were
not informed about which group they were assigned
to (Fig. 1b). This study firstly evaluated the short-term
effects of simulation-based education combined with
PAL as prior training for emergency medicine by written examinations, which was performed shortly after
the training. Secondly, we evaluated the middle-term
effects by assessing the residents’ clinical performancesFig. 1 Research design and structure. a Performed tests and questionnaires before and after the 2-week clinical orientation. For the simulationand lecture group, three sessions of simulation training and lecture training were held during the orientation period. b During the clinical practice,self-evaluation questionnaires and objective-assessment checklists were used to assess residents after each performance of emergency department
dutiesMurakami et al. BMC Medical Education(2023) 23:859

during their first emergency department duties, which
was performed approximately one to two weeks after theprior training. Finally, we evaluated the long-term effects
by following up the residents for three months after theprior training and continuing their assessment during
emergency department duties.
The results of the pre-test and post-test during theorientation period, as well as the results of each element of the self-evaluation questionnaire and objectiveassessment checklist for emergency department duties,
were statistically analyzed and compared by their meansamong the three groups. IBM SPSS Statistics 26™ and
Prism 9 for Mac™ (Version 9.5.0) was used for statistical analyses. Chi-square tests were applied to categoricalvariables such as resident demographics. Paired t-tests
were applied to compare continuous variables between
the pre-tests and post-tests within the individual groups,
and one-way analysis of variance (ANOVA) were applied
to compare continuous variables of the pre-tests andpost-tests among all three groups. For the evaluation of emergency department duties, student t-tests
were applied to compare continuous variables between
the simulation group and the lecture group. One-way
ANOVA were applied to compare continuous variables
obtained from each emergency department duties among
all three groups, and repeated measures ANOVA wereapplied to compare continuous variables obtained fromthe multiple emergency department duties within theindividual groups. No information of members and contents of the prior trainings were given to evaluators or
fellow residents to avoid any potential confounders andPage 4 of 10

bias as possible. For the simulation and lecture groups,
in which prior training was provided as an educational
intervention, principal component analysis (PCA) was
performed for all elements of the self-evaluation questionnaire and the objective-assessment checklist. The
study was conducted in accordance with the appropriate
procedures of the research program at the Okayama University Hospital, and permission was obtained from the
ethics committee (No. 1602-039). To eliminate any inequities in the initial clinical training of medical residents,
equal opportunities were ensured for PGY-I residents toattend both simulation- and lecture-based prior training
after the evaluation period of the study upon request.

Results
A total of 75 residents were included in the comparative study: 27 in the simulation group, 24 in the lecturegroup, and 24 in the control group (Fig. 2). No significant differences were found between the three groups
in the demographics of the residents, as obtained using
a questionnaire during the clinical orientation period(Table 1a). In addition, no significant differences were
found between the groups in the pre-test results during
the orientation period (Table 2; Fig. 3a, b). Furthermore,no significant differences were found between the groups
in the future department of choice obtained from a follow-up survey performed after the initial clinical trainingof the PGY-I residents (Table 1b).
A comparison between the pre-test and post-test scoresof the three groups during the orientation period showeda significant increase in the mean score (simulation

Fig. 2 Inclusion and exclusion criteria. A total of 108 first-year medical residents were randomized and divided into three groups, and 75 wereanalyzed: the simulation group (n = 27), lecture group (n = 24), and control group (n = 24)

Murakami et al. BMC Medical Education(2023) 23:859

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Table 1 Demographics of the participants
Demographics from the pre orientationquestionnaire

Number of residents (%)
Simulation

LectureControlMale

15 (56)15 (62)18 (75)

Female12 (44)9 (38)

6 (15)

Experienced simulation-based education
in medical school

22 (82)16 (67)22 (92)

Experienced being a tutor of simulation-based 3 (11)education

3 (13)2 (8)Willing to instruct simulation-based education 14 (58)

11 (46)14 (58)Belonged to a study group or training clubin medical school

11 (41)7 (29)

8 (33)

Graduated from Okayama University medical
school10 (37)

11 (46)

10 (42)

Graduated from other university medical
schools

17 (63)13 (54)14 (58)(a) Demographics of PGY-I residents based on the pre orientation questionnaire collected at the beginning of the clinical orientation
Statistically analyzed by Chi-square test
Demographics from the post medical
training questionnaire

Number of residents (%)
Simulation

LectureControlInternal Medicine Department for futurespecialty

11 (41)

10 (42)12 (50)Surgical Department for future specialty

14 (52)13 (54)10 (42)(b) Demographics of PGY-I residents based on the post medical training questionnaire collected after the completion of the initial medical training.
Statistically analyzed by Chi-square test

group, pre-test score 52.7 [11.8] vs. post-test score 69.9
[9.3], p = 0.010; lecture group, pre-test score 55.9 [14.0]
vs. post-test score 72.6 [10.9], p = 0.010; control group,
pre-test score 55.1 [13.1] vs. post-test score 61.4 [10.6],
p = 0.010) (Fig. 3a). In the pre-test, there were no significant differences in the mean scores among the threegroups. For the post-test, the simulation and lecturegroups showed a significant increase in the mean scorescompared to the control group (simulation group posttest score 69.9 [9.3] vs. control group post-test score 61.4
[10.6], p = 0.014; lecture group post-test score 72.6 [10.9]
vs. control group post-test score 61.4 [10.6], p = 0.010). A
comparison between the simulation and lecture groups

Table 2 Knowledge evaluation using pre-test and post-testscoresPre-test
Mean

Post-test
SD

Mean

SD

Difference

Simulation group

52.7

11.8

69.9

9.3

17.2

Lecture group

55.9

14.0

72.6

10.9

16.8

Control group

55.1

13.1

61.4

10.6

6.3

Mean, standard deviation (SD), and score differences in the pre- and post-tests
for each group

showed no significant differences in the mean scores ofthe post-test (Fig. 3b).
For evaluating the efficacy of prior training for emergency department duties, the results of the self-evaluationquestionnaire were compared between the simulationand lecture groups. The simulation group showed a significantly higher rating for assessing whether prior training was useful for emergency department duties thanthe lecture group for all 1st, 2nd, and 3rd emergency
department duties (1st emergency department duty,
simulation group rate 7.3 [1.8] vs. lecture group rate 5.0[2.3], p = 0.001; 2nd emergency department duty, simulation group rate 7.4 [2.1] vs. lecture group rate 5.2 [1.9],
p = 0.001; and 3rd emergency department duty, simulation group rate 7.1 [1.9] vs. lecture group rate 4.9 [1.9],
p = 0.003) (Fig. 4). Moreover, for evaluating the impact ofprior training, PCA of the elements of the self-evaluationquestionnaire and the objective-assessment checklist
revealed a tendency for the simulation group to have ahigher rating on the self-evaluation questionnaire thanthe lecture group (Fig. 5).
No significant differences were observed among thethree groups in the mean rate of the self-evaluation questionnaire and that of the objective-assessment checklist for evaluating the clinical performance of PGY-I

Murakami et al. BMC Medical Education(2023) 23:859

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Fig. 3 Evaluation of the pre-test and post-test scores. a Post-test scores were significantly higher than pre-test scores in all three groups. b Post-testscores were significantly higher in the simulation and lecture groups than in the control group. Statistically analyzed by paired t-test and one-way
ANOVA. Whiskers indicate standard deviation values

Fig. 4 Usefulness of the prior training. Simulation group finds
their prior training more useful compared to the Lecture group.
Statistically analyzed by Student’s t-test (1st emergency department
duty: mean rate of the simulation group 7.26, and the lecturegroup 4.96, p = 0.001. 2nd emergency department duty: mean rateof the simulation group 7.41, and the lecture group 5.16, p = 0.001.
3rd emergency department duty: mean rate of the simulationgroup 7.10, and the lecture group 4.94, p = 0.003) Whiskers indicate
standard deviation values

residents during emergency department duties (Fig. 6a).
However, evaluating the improvement rate of the resident performances over time by comparing the resultsof the 1st, 2nd, and 3rd emergency department duties
through a repeated measures ANOVA, all three groups
showed a significant increase in the mean rate of the selfassessment questionnaire. The simulation group showedsignificant improvement between the 1st and 3rd emergency department duties (1st emergency department
duty rate 5.0 [1.7] vs. 3rd emergency department duty

rate 6.0 [1.7], p = 0.029); the lecture group showed significant improvement between the 1st and 3rd emergency
department duties (1st emergency department duty ratemean 4.3 [1.3] vs. 3rd emergency department duty rate
5.1 [1.4], p = 0.025); and the control group showed significant improvement between 1st and 2nd (1st emergency department duty rate 4.5 [1.1] vs. 2nd emergency
department duty rate 5.5 [1.3], p = 0.011) as well as 1st
and 3rd emergency department duties (1st emergency
department duty rate 4.5 [1.1] vs. 3rd emergency department duty rate 5.5 [1.1], p = 0.004). From the resultsof the objective-assessment checklist, the simulationgroup showed significant improvement between the 2nd
and 3rd emergency department duties (2nd emergency
department duty rate 6.8 [1.1] vs. 3rd emergency department duty rate 7.4 [0.9], p = 0.044) through a repeatedmeasures ANOVA and post-hoc comparison (Tukey),
and the lecture group showed significant improvement
between the 1st and 3rd emergency department duties(1st emergency department duty rate 6.6 [1.4] vs. 3rd
emergency department duty rate 7.6 [1.0], p = 0.019),
whereas the control group showed no significant
improvement in performance during emergency department duties over time (Fig. 6b).
Pearson’s correlation test was used to evaluate theassociation between the demographics of the PGY-I
residents, the scores of the written examinations, andthe mean rates of performance during the emergency
department duties, but the results showed no significant
correlation. Additionally, one-way ANOVA was used tocompare the improvement rate of emergency department
performance among the three groups. Stratified analyses
were performed by independently evaluating residents
with average or higher scores on the written examinations and those with lower scores; however, no significant
trend was obtained (data not shown).

Murakami et al. BMC Medical Education(2023) 23:859

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Fig. 5 Principal component analysis. The principal component (PC) analysis of the self-evaluation questionnaire and the objective-assessment
checklist of all emergency department duties for both the simulation and lecture groups shows the tendency of the simulation group to havehigher rate on the self-evaluation questionnaire than the lecture group. The first 2 components (contributing 47.89% of variance) were plotted

Discussion
All three groups showed significant improvement in themean scores on the post-test compared with the pre-test.
However, comparing the improvement rate of the mean
test scores, simulation and lecture groups showed significantly greater improvement than the control group.
These results are consistent with previous reports indicating that educational interventions during the clinicalorientation period can improve PGY-I residents’ knowledge [13–15]. In addition, a previous study showed that
PAL combined with simulation-based education has abetter learning effect than lecture-based education in ashort-term evaluation [7]. This study showed no significant differences in test scores between the simulation andlecture groups. However, the groups that received priorclinical training showed a significant increase in mean
test scores compared to the group that did not, which isconsistent with previous reports that educational intervention based on PAL has positive effects on improving
test scores [13, 15].
Previous studies have shown that PAL has greater
learning effects than conventional education; in particular, PAL combined with simulation-based education has
been suggested to be highly effective [6–8]. In this study,
PAL was employed during the orientation period, andboth the simulation and lecture groups performed significantly better on the written examination than the control
group, which is consistent with a previous study by Yamamoto et al. [7], indicating the short-term efficacy of PAL.
Furthermore, the evaluation of the emergency department performance of PGY-I residents showed a significant increase in the improvement rate over time for theobjective assessment of the simulation and lecture groups
whereas the control group showed no significant changes,
suggesting that prior training based on PAL can improve
performance during emergency department duties.
A previous study adopted PAL with PGY-II residents
teaching PGY-I residents and noted that, as one of theadvantages of PAL, young learners felt more comfortableasking questions compared to cases in which more experienced doctors were teaching [7]. The PAL adopted inour study may have created an environment in which the
PGY-I residents were encouraged to ask questions, thus
promoting effective learning. However, this study did notinvestigate the effects of experienced doctors teaching
PGY-I residents, nor did it investigate the effects of PAL
on PGY-II residents; further studies are needed. Examining the correlation between PGY-I residents’ demographics, test scores, and performance during their emergency
department duties showed no consistent trends. Therefore, we believe that prior training through simulationbased learning based on PAL has a universal educational
effect regardless of resident characteristics.
Comparing the effects of prior training on the simulation and lecture groups, there were no significant differences in the test scores during the orientation period
or in the performance during emergency department
duties. However, when asked in the self-evaluation questionnaire whether the PGY-I residents felt that theirprior training was useful in the performance of theiremergency department duties, the simulation groupreported significantly higher satisfaction than the lecture group and reported that they felt their prior training
was effective. Furthermore, PCA of the self-evaluation

Murakami et al. BMC Medical Education(2023) 23:859

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Fig. 6 Comparison of the results of the self-evaluation questionnaire and objective-assessment checklist. a One-way ANOVA showed no significant
differences among the three groups in the results of the questionnaire and checklist during the 1st to 3rd emergency department duties. b Repeatedmeasures ANOVA showed that all three groups have significantly higher self-evaluation questionnaire ratings throughout the 1st to 3rd emergency
department duties. The simulation and lecture groups have significantly higher objective-assessment checklist ratings whereas the control group
showed no significant difference throughout the 1st to 3rd emergency department duties. Whiskers indicate standard deviation values

questionnaire and the objective-assessment checklist
during emergency department duties showed a tendency
for the simulation group to have higher rates on the
self-evaluation questionnaire than the lecture group.
These results suggest that prior training in simulationbased education based on PAL may be more satisfactory
than lecture-based education and may lead to higher
self-evaluation in clinical practice. Ten et al. [16] also
reported satisfaction with simulation-based learning,
and the results of our study are consistent with previous
findings in the context of simulation-based education
having greater satisfaction than lecture-based education
for prior training in emergency department duties.

There were no significant differences among the threegroups in PGY-I resident performance during emergency
department duties according to the results of the selfevaluation questionnaires and the objective-assessment
checklists. However, by evaluating the improvement ratesof PGY-I resident performance during their emergency
department duties, the simulation and lecture groups
showed significantly higher scores compared to the control group according to the results of the objective-assessment checklists. Thus, these results suggest that priortraining based on PAL may have a long-term beneficial
effect on the performance improvement rate of PGY-I
residents during emergency department duties. AlthoughMurakami et al. BMC Medical Education(2023) 23:859

the evaluation period in this study was only threemonths, the observed increase in the improvement rateof performance during emergency department duties forthe groups that received prior training suggests the possibility of further improvement in clinical performanceover time, and further long-term evaluations are neededin the future. While previous studies have reported
simulation-based education to be more effective than
lecture-based education [17], this study found no significant differences between the learning effects of simulation-based education and lecture-based education for
written examinations and emergency department duty
performance. However, simulation-based education was
found to be more effective for improving self-evaluationand increasing satisfaction for residents. Therefore, conducting prior training in emergency department duties
via simulation-based education combined with PAL may
not only lead to improving the work performance of theresidents but may also contribute to improving resident
motivations toward better clinical practices. A previous
study also reported an increase in self-learning time asa short-term effect of simulation-based education combined with PAL [7]. As a long-term effect, such changes
in behavior and awareness are expected to improve work
performance in PGY-I residents.
The most notable limitation of this study is the continuity and the repeatability of simulation-based education asprior training for emergency medicine. Also, the fact thatthe study design did not completely restrict residents’interactions and individual learnings may be a potential
source of bias. In addition, this study was conducted asa single-center study limiting the number and variety of
the residents evaluated, which may be a possible restriction for generalization of the results. A possible reason
for the lack of significant differences in performance
during emergency department duties among the threegroups is that no additional educational intervention
was provided after the initial orientation sessions. Previous studies have shown that the duration of the learning effects of simulation-based education is limited overtime, and repeated educational interventions are necessary for the retention of learning contents [18, 19]. To
achieve significant improvements in work performance,
multiple interventions may be necessary after starting
the emergency department duties to avoid long intervals
between the training and actual clinical practices. For
future research, study design with repeated educational
intervention is recommended to further investigate
the long-term impact of simulation-based education.
Another possible factor that may have influenced theresults of this study is that, although the assignment of
PGY-I and PGY-II residents into groups was anonymous
to avoid any bias, because the control group received

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no prior training, incentives to study privately may havebeen promoted for the residents assigned to the control
group because of competitive consciousness among theresidents. In addition, this study was conducted at a university hospital in Japan, where advanced and specialized
medical services are provided, and medical practices,
as well as the types of diseases and patients, differ fromthose of primary care hospitals. Although the case study
scenarios for prior training in our study were developed
as common cases that medical residents encounter during emergency department duties, adjusting the casestudy scenarios considering the role and characteristicsof the institutions where prior training is provided may
result in a more effective educational investigation.
Ensuring financial costs as well as faculty time andeducation is important for preparing prior trainings, andfurther evaluations are needed [20, 21]. In this study, no
additional financial costs were necessary because preexisting facilities, including the simulator, were utilized forprior training. The time and human costs necessary forproviding prior training were reduced by accumulatingcase study scenarios and educational programs. Thus,
for institutions where simulators and facilities for simulation-based education are already available, simulationbased education may be a decent choice for the means ofprior training in emergency medicine, especially in termsof medical residents’ satisfaction.

Conclusions
The objective of this study was to assess the middle- to longterm effects of prior training using different educational
methods combined with PAL through a case-control trial
design. The results indicated that both simulation-based
and lecture-based education combined with PAL enhanced
the clinical knowledge of medical residents. Prior training
in the form of simulation-based or lecture-based education
demonstrated the potential to enhance the clinical performance of medical residents during emergency department
duties. Additionally, when comparing simulation-based andlecture-based education, simulation-based education was
associated with a significantly higher level of satisfaction
among medical residents. This study was conducted on asmall scale at a university hospital in Japan. Further largescale and long-term studies in various medical institutions
are needed to provide a more comprehensive evaluation.
Abbreviations
PAL	Peer-assisted learning
PGY-I	Postgraduate-year-one
PGY-II	Postgraduate-year-two
ANOVA	Analysis of variance
PCA	Principal component analysis
SD	Standard deviation

Murakami et al. BMC Medical Education(2023) 23:859

Acknowledgements
This study was supported by the Postgraduate Clinical Training Center, the
MoMoSim Simulation Center, and the Center for Education in Medicine and
Healthcare Sciences of Okayama University Medical School and Okayama
University Hospital.
Authors’ contributions
T.M. (Taku Murakami) and A.Y. was the central in conceiving the research,coordinating the activities, collecting the data, analyzing it, and interpreting
it. T.M. (Taku Murakami) was the central in drafting the initial manuscript.
A.Y., H.H., and M.O. was the central in the revision of the manuscript. T.M.
(Tomoko Miyoshi), Y.M., and H.K. designed the research and contributed tothe methodology, software, and resources. M.O. contributed to the funding of
the research. F.O. supervised the research and analyzed the data. All authors
contributed to the revision of the manuscript, approved the final version andare accountable for the accuracy and integrity of the consent.

Page 10 of 10

8.
9.

10.

11.
12.

Funding
This research was funded in part by JSPS KAKENHI Grant Number 21K10327.

13.

Availability of data and materials
The datasets used and/or analyzed during the current study are available fromthe corresponding author on reasonable request.

14.

Declarations

15.

Ethics approval and consent to participate
Informed consent was obtained from all participants.
This study was approved by the Ethics Committee of Okayama University
Medical School (No. 1602-039, approved on 24 February 2015).

16.

Consent for publication
Obtaining a consent for publication was required by the Ethics Committee
and thus was obtained from all participants.

17.

Competing interests
The authors declare no competing interests.

18.

Author details
1
Department of General Medicine, Dentistry and Pharmaceutical Sciences,
Okayama University Graduate School of Medicine, 2‑5‑1 Shikata‑cho, Kita‑ku,
Okayama, Japan. 2 Department of Hematology and Oncology, Okayama
University Hospital, 2‑5‑1 Shikata‑cho, Kita‑ku, Okayama City, Okayama, Japan.
3
Department of Emergency Medicine, The JIKEI University, 3‑25‑8 Nishi‑Shinbashi, Minato‑ku, Tokyo, Japan. 4 Diversity Enhancement Center, Okayama
University Hospital, 2‑5‑1 Shikata‑cho, Kita‑ku, Okayama City, Okayama, Japan.
Received: 9 April 2023 Accepted: 22 October 2023

19.
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