Background <p>Simulation-based education is a crucial element of medical training, providing safe and realistic environments to develop clinical skills and confidence. This study evaluates the effects of three key simulation methods—Standardized Patients (SP), High-Fidelity Simulators (HFS), and Virtual Reality (VR)—on medical students’ engagement and clinical performance confidence.</p> Methods <p>The study involved 43 fifth-year medical students from the Ajou University School of Medicine during a respiratory clinical rotation. The students participated in SP-, HFS-, and VR-based simulation education. After each simulation module, their engagement (interest, flow, relevance) and clinical confidence (history taking, physical examination, interacting and communicating with patients, clinical reasoning) were assessed using self-report surveys. A Multivariate Analysis of Variance was conducted to analyze differences in engagement and confidence across the simulation modules.</p> Results <p>The simulation methods had little significant effect on students’ learning engagement or its sub-factors. However, there were significant differences in clinical performance confidence depending on the simulation module. Confidence in history taking, physical examination, and interacting and communicating with patients were significantly higher when using SP compared to HFS and VR.</p> Conclusion <p>This study provides practical guidance for designing and developing clinical training curricula by directly comparing the effects of various simulation-based education methods. The results suggest that SP-based simulation education is particularly effective in enhancing medical students’ confidence in clinical settings. While VR and HFS offer advantages in immersion and realism, the experience of interacting with actual patients remain crucial for boosting clinical performance confidence. These findings offer crucial insights for optimizing medical education and improving clinical competencies of medical students.</p>