
==== Front
BMC Med Educ
BMC Med Educ
BMC Medical Education
1472-6920
BioMed Central London

39266995
5973
10.1186/s12909-024-05973-3
Research
A combination of case-based learning with flipped classroom improved performance of medical students in nephrology bedside teaching
Hu Bibi 1
Wang Li 2
Wu Junxia 3
Zhu Lina 3
Chen Zhida 2316066@zju.edu.cn

3
1 https://ror.org/059cjpv64 grid.412465.0 Nursing Department, School of Medicine, The Second Affiliated Hospital of Zhejiang University, Hangzhou, China
2 https://ror.org/00a2xv884 grid.13402.34 0000 0004 1759 700X Department of Emergency, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
3 https://ror.org/00a2xv884 grid.13402.34 0000 0004 1759 700X Department of Nephrology, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
12 9 2024
12 9 2024
2024
24 9956 3 2024
30 8 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Bedside teaching remains a challenging endeavor for clinical doctors and medical students, as the students often encounter difficulties in applying their knowledge to clinical situations. This study aims to evaluate the efficacy of combining case-based learning (CBL) with a flipped classroom (FC) approach in nephrology bedside teaching.

Methods

A total of 92 medical students were enrolled in this study, including clerks and interns. The students were assigned into two groups. The CBL/FC group students received the combined teaching approach of CBL and FC (CBL/FC). Students who received the traditional lecture-based teaching (LBT) approach were treated as the control group. General knowledge tests, clinical case scenarios, and questionnaires were used to evaluate the teaching efficacy.

Results

Ninety-two students were included in this study. Overall, 46 students were assigned to the CBL/FC group, while the other 46 students were assigned to the LBT group. The students in both groups showed comparable performance in the knowledge test. However, in clinical case scenarios, students in the CBL/FC group demonstrated superior performance compared to those in the LBT group. Additionally, the analysis of questionnaires revealed that the CBL/FC group students expressed more positive attitudes toward their proficiency in medical history taking, physical examination, medical record documentation, clinical reasoning, and consideration for patients’ welfare. Moreover, the students from the CBL/FC group regarded the CBL/FC teaching approach as an effective and satisfying method without increasing the learning burden.

Conclusion

This study reveals that the CBL/FC combined teaching approach shows promise in nephrology education and provides an effective and alternative format for medical teaching.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-05973-3.

Keywords

Case Based Learning
Flipped Classroom
Teaching effect
Nephrology
Medical students
Teaching Reform and Cultivation Project of the Second Clinical Medical College of Zhejiang University20230242 20210209 the 2023 General Research Project of the zhejiang Provincial Department of EducationY202351977 issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Towards the end of their undergraduate education, medical students face a transition from students to interns, requiring them to apply their problem-solving skills in a clinical setting [1]. The factors that cause human diseases are complex and medicine is a highly practical discipline; hence, the basic medical knowledge acquired from school is insufficient to meet the requirements of clinical practice. New interns are often confused about managing clinical problems, as they are faced with the challenge of applying theoretical knowledge to clinical practice [2]. Bedside teaching is an effective mode of medical education, helping interns to apply their knowledge to real-world clinical work [3]. However, the traditional instructional approach emphasizes the delivery of core knowledge to students and overlooks the development of clinical thinking and problem-solving. Therefore, students cannot integrate theoretical knowledge with clinical knowledge. Moreover, long-term passive acquisition of knowledge that is poorly applied to clinical practice dampens students’ enthusiasm for learning [4, 5].

Traditionally, lecture-based teaching (LBT) has been the most common method of teaching. This approach is commonly used in teaching medical knowledge and clinical skills and represents an easy and effective method to show the students general knowledge and concepts. However, during clinical teaching, LBT does not effectively engage students in developing critical reasoning skills. In addition, LBT is teacher-centered, so the knowledge transmission depends highly on the teachers [6, 7].

In contrast, case-based learning (CBL) is a learner-centered method that promotes interaction among participants as they collaborate to build their knowledge and examine the case together as a group. CBL has been widely used around the world for medical education [8]. CBL facilitates the development of students’ clinical performance and teamwork, encouraging them to solve clinical problems with their theoretical knowledge and critical thinking. It is a student-centered teaching methodology that exposes students to real-world scenarios [9]. Previous studies comparing the CBL method to the traditional teaching method in medical students have demonstrated that CBL is more effective in improving students’ problem-solving skills [10, 11].

Flipped classroom (FC) is another student-centered teaching approach that is widely used in medical education. The FC approach allows students to watch instructional videos online before class. In class, teachers and students primarily interact and converse, and teachers answer questions to enable learners to internalize their lessons [12]. By freely managing their time while learning online and repeatedly learning complex knowledge, students maximize the efficiency of classroom learning [13]. The most recent research revealed that students in FCs consistently exhibited higher levels of satisfaction, motivation, and engagement, as well as more positive academic outcomes compared to traditional lecture-based learning (LBL) [14, 15].

Both the CBL approach and the FC approach are beneficial to student learning, while the effects of the combined usage of CBL and FC in nephrology education remain poorly understood. Therefore, this randomized control study investigated 92 medical students to evaluate the effectiveness and acceptability of the combined approach (CBL/FC). This study compared the performance in general knowledge tests, clinical case scenarios, and questionnaires between students who received the CBL/FC approach and LBT approach. The CBL/FC approach was compared with traditional LBT teaching in undergraduate students and evaluated the advantages of this teaching model to provide new strategies for undergraduate medical education.

Methods

Participants

A total of 92 undergraduate students were included in this study, who all majored in clinical medicine at Zhejiang University, School of Medicine. The students undertook a clinical rotation in the Department of Nephrology, Second Affiliated Hospital of Zhejiang University, between January 2022 and January 2023.

The inclusion criteria were (1) attended the hospital for pre-clerkship or clerkship training, (2) first time to attend the clinical rotation in the Department of Nephrology, and (3) having a presence of over 90% over the training period. The exclusion criteria were (1) refusing participation, (2) an absence rate of 10% or more over the training period, and (3) dropping out for other reasons.

All students enrolled in this study have attended the nephrology lectures taught by the same instructors beforehand. Before the study enrolment, the participants were required to take examinations containing a general knowledge test and clinical case scenarios related to nephrology. The students’ baseline performance was assessed according to the results of the examination. The students were randomly assigned to two groups based on their year of grade in the school. Students in Group A received the CBL and FC combined approach, while students in Group B received the traditional LBT approach as a control group. General knowledge tests, clinical case scenarios, and questionnaires were used to evaluate the teaching efficacy.

All the teachers participating in this study were voluntarily included. They were experienced teachers in clinical teaching and were trained before teaching.

Study design

All students received the CBL/FC approach or LBT approach between January 2022 and January 2023. The study flow is displayed in Fig. 1. In brief, the teachers prepared the same topic for the two groups. In Group A (CBL/FC group), students were divided into small groups comprised of 4 or 5 persons. Teachers were required to prepare topic-related materials (including related cases, PowerPoint materials, and handouts), which were delivered to the students one week before the class. The students were requested to preview the topic-associated materials and prepare slides for a case presentation. The class began with the teachers introducing the topic, and the students presented their case, followed by a discussion. Students placed themselves in the role of the decision-maker and identified the problems they faced using the knowledge they learned. Next, students performed the necessary analysis, including the clinical diagnosis, differential diagnosis, further examination, and therapeutic regimen. Finally, the teachers answered the questions raised by students and summarized the corresponding pitfalls and pearls. After the class, the teachers assigned after-school thinking questions to the students and prepared the case for the next class. Students were requested to review the textbook and prepare for the exam. In Group B (LBT group), the teachers prepared slides about the class topic by themselves, while students were not informed in advance about the new content for the next class. During class, the teachers lectured about the class topic and answered the students’ questions. At the end of the class, the teachers provided a summary of the topic and left some homework for the students. The study design was approved by the Institutional Review Board and Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine. All students involved in the study signed informed consent forms.

Fig. 1 Schematic representation of the interventions. A: Schematic representation of the CBL/FC approach; B: Schematic representation of the LBT approach. CBL, case-based learning; FC, flipped classroom; TBL, lecture-based teaching

Evaluation

To evaluate the outcomes of the intervention, the students from the two groups were assessed by a general knowledge test and clinical case scenario on their last day in our department. The general knowledge test was composed of multiple-choice questions, with each question bearing the same weight. The students were required to participate in clinical practice as doctors do in clinical case scenarios, including medical history collection, physical examination, record writing, clinical thinking, and care for patients. The scenarios used for assessment were never presented in the teaching process for students in the CBL/FC group. Moreover, we had provided specialized training to familiarize both groups of students with the format of the exam. The clinical case scenarios used for assessment were the same between the two groups. Finally, the students were scored according to their performance. All students from both groups were required to complete a questionnaire, which was used to understand the perspectives and experiences of the students regarding the teaching models using a five-point Likert scale. The items covered questions about improving the ability of medical history collection, physical examination, record writing, clinical thinking, and care for patients, as well as the time spent for the class, the satisfaction with the teaching method, and recommendation of this method. The questionnaire was modified from Paul Ramsden’s Course Experience Questionnaire and Biggs’ Study Process questionnaire with verified reliability and validity [2, 16, 17]. The questionnaire is listed in the Supplementary Materials.

All methods were carried out in accordance with relevant guidelines and regulations.

Statistical analysis

All data were presented as mean ± standard deviation of mean (SD) and analyzed on GraphPad Prism 9.0. The independent sample t-test was performed to compare exam scores between groups. In addition, the chi-square test was performed to compare the gender distribution between the two groups. The Mann-Whitney test was performed to compare the age and questionnaire outcomes between groups. In this study, P < 0.05 was considered statistically significant.

Results

Participant characteristics

A total of 48 of the students were in their fourth grade of medical school, and 44 were in Grade 5. The ages of the students ranged from 20 to 22 years old. At the start of the study, 46 students were randomly assigned to the CBL/FC group, and the other 46 students were assigned to the LBT group. As displayed in Table 1, the average age, male/female, and grade showed no significant difference between the two groups.

Table 1 Participant characteristics

	CBL/FC Group
(N = 46)	LBT Group
(N = 46)	P values	
Age (Years old, Mean ± SD)	21.15 ± 0.92	20.85 ± 0.92	0.115	
 Grade 4 (N = 24)	20.50 ± 0.78	20.17 ± 0.48	0.082	
 Grade 5 (N = 22)	21.86 ± 0.35	21.59 ± 0.67	0.131	
Gender (Male/Female)	19/27	22/24	0.529	
 Grade 4 (N = 24)	9/15	12/12	0.383	
 Grade 5 (N = 22)	10/12	10/12	1.000	

Students’ performance in the exam

Before the interventions, the students’ baseline performance was assessed. The scores of the examination were analyzed and the results revealed no significant difference between these two groups (Fig. 2A and B). In the general knowledge test, the average score in the CBL/FC group was 94.07 ± 4.86, while the score was 93.04 ± 5.33 in the LBT group, revealing a similar performance in both groups (P > 0.05, Fig. 3A). However, in the clinical case scenarios, the students in the CBL/FC group demonstrated a superior performance to that of the LBT group (P < 0.05), as shown in Fig. 3B.

Fig. 2 The performance of students before the interventions. A/B: The performance of students in Grade 4 before the interventions. A: The students in the two groups showed similar performance in general knowledge test, 83.96 ± 4.63 vs. 84.12 ± 4.87, P = 0.90. B: The students in the two groups showed similar performance in clinical case scenarios, 55.46 ± 14.86 vs. 55.88 ± 13.12, P = 0.92. C/D: The performance of students in Grade 5 before the interventions. C: The students in the two groups showed similar performance in general knowledge test, 87.41 ± 4.68 vs. 87.73 ± 4.05, P = 0.81. D: The students in the two groups showed similar performance in clinical case scenarios, 71.09 ± 11.49 vs. 69.82 ± 13.86, P = 0.74. Data are presented as mean ± SD. NS, no statistical significance

Fig. 3 The performance of students after the interventions. A: General knowledge test scores. The students in the two groups showed similar performance, 94.07 ± 4.86 vs. 93.04 ± 5.33, P = 0.34. B: Clinical case scenarios. The students in the CBL/FC group scored higher than students in the LBT group, 80.39 ± 15.05 vs. 71.43 ± 15.61, P = 0.01. Data are presented as mean ± SD. * P < 0.05; NS, no statistical significance

All the students in the same grade were pooled together, indicating that students in Grade 4 performed better in the general knowledge test (Grade 4: 96.67 ± 4.42 vs. Grade 5: 90.16 ± 3.33, P < 0.01), whereas students in Grade 5 performed better in the clinical case scenarios tests (Grade4: 70.50 ± 16.02 vs. Grade 5: 81.82 ± 13.64, P < 0.01). Additionally, the same trend was observed when comparing the test scores of the students in different grades (Fig. 4A and B).

Fig. 4 The performance of students after the interventions in different groups. A: Students in Grade 4 performed better in the general knowledge test compared to students in Grade 5, 96.67 ± 4.42 vs. 90.16 ± 3.33, P < 0.01. Similar results were found in subgroups based on the teaching method: in the CBL/FC group, Grade 4: 97.08 ± 3.88 vs. Grade 5: 90.77 ± 3.53, P < 0.01; in the LBT group, Grade 4: 96.25 ± 4.94 vs. Grade 5: 89.55 ± 3.08, P < 0.01. B: Students in Grade 5 performed better in clinical case scenarios than students in Grade 4, 70.50 ± 16.02 vs. 81.82 ± 13.64, P < 0.01. Similar results were found in subgroups based on the teaching method: in the CBL/FC group, Grade 4: 75.13 ± 16.63 vs. Grade 5: 86.14 ± 10.79, P = 0.01; in the LBT group, Grade4: 65.88 ± 14.26 vs. Grade 5: 77.50 ± 15.02, P = 0.01. Data are presented as mean ± SD. *P < 0.05, **P < 0.01

Students’ experience survey.

Students’ perceptions and experiences were evaluated using a questionnaire. All the students in this study were required to complete the questionnaire. The Cronbach’s alpha for positive items of the questionnaire was calculated as 0.84, which indicated the satisfactory internal consistency and reliability of the questionnaire. The students in Grade 4 in the CBL/FC group provided a more positive perception of improving the ability of medical history collection (4.25 ± 0.79 vs. 3.25 ± 0.74, P < 0.01), physical examination (4.29 ± 0.75 vs. 3.29 ± 0.75, P < 0.01), record writing (4.63 ± 0.49 vs. 3.63 ± 0.82, P < 0.01), clinical thinking (4.33 ± 0.70 vs. 3.79 ± 0.72, P = 0.01), and support for patients (4.38 ± 0.65 vs. 3.25 ± 0.85, P < 0.01) compared to the LBT group. The time spent before the class showed no difference between the two groups (2.92 ± 0.28 vs. 3.17 ± 0.96, P = 0.23). However, the CBL/FC group students were more satisfied with the class (4.21 ± 0.72 vs. 3.54 ± 0.83, P < 0.01). Similarly, the students in Grade 5 in the CBL/FC group also held a more positive perception of improving the ability of medical history collection (4.68 ± 0.48 vs. 3.91 ± 0.75, P < 0.01), physical examination (4.55 ± 0.60 vs. 3.73 ± 0.70, P < 0.01), record writing (4.59 ± 0.59 vs. 3.36 ± 0.85, P < 0.01), clinical thinking (4.64 ± 0.49 vs. 3.55 ± 0.91, P < 0.01), and support for patients (4.68 ± 0.48 vs. 3.86 ± 0.83, P < 0.01) compared to the LBT group. The time spent before the class showed no difference between the two groups (3.18 ± 1.14 vs. 3.14 ± 0.64, P = 0.87). However, the CBL/FC group students were more satisfied with the class (4.27 ± 0.55 vs. 3.09 ± 0.97, P < 0.01) (Fig. 5A and B).

Fig. 5 The students’ perspectives on the teaching modality. A: Experience survey of students in grade 4. B: Experience survey of students in grade 5. The students in the CBL/FC group reported a more positive perception of improving the ability of medical history collection, physical examination, record writing, clinical thinking, and support for patients (P < 0.05). The time spent before the class showed no significant difference between groups (P > 0.05). However, the CBL/FC group students were more satisfied with the class (P < 0.05). Data are presented as mean ± SD. *P < 0.05, **P < 0.01; NS, no statistical significance

Discussion

Clinical learning during an internship remains a challenge for medical students. Traditional clinical teaching methods such as LBT do not fulfill the requirements for current medical education [18, 19]. Thus, new strategies should be explored to improve the medical students’ clinical thinking ability and problem-solving ability.

Compared to simple FC teaching, a previous study revealed that case-based and team-based learning (CTBL) combined with FC (FC/CTBL) was superior in teaching residents, effectively improving their teamwork, clinical thinking, and confidence to solve problems by themselves [20]. The results indicate that a combination of multiple teaching methods could improve the student’s performance and learning efficiency. The CBL approach is a long-established pedagogical method, which aims to help students link theoretical knowledge with clinical practice. In this approach, instructors show the clinical history of patients with typical symptoms and students place themselves in the role of the decision-maker, applying the knowledge they learned [21]. The FC approach is a student-centered active learning strategy, which allows students to review instructional content outside the classroom and take part in interactive learning under the teacher’s guidance, allowing students to internalize their lessons. The FC approach has shown greater academic achievement for higher-level learning outcomes compared to traditional LBT and students considered FC beneficial to comprehension, critical thinking, and teamwork [22]. Overall, the CBL approach motivates students and facilitates the association between student learning and real-life situations. Furthermore, the FC approach emphasizes the initiative of students and promotes the development of the students’ abilities to analyze and solve problems. Hence, the present study combined FC with CBL. This study’s findings suggested that students in the CBL/FC group performed better in clinical case scenarios and felt more motivated to learn compared to those in the traditional LBT group.

This study demonstrated that students in the CBL/FC group scored higher than those in the LBT group for the tests of clinical case scenarios. However, the students from both groups achieved similar scores in the general knowledge tests. These results were consistent with those of previous studies. The CBL approach has been considered to provide a relaxed, non-threatening environment, which introduces students to clinical skills in a way that fosters their confidence for future clinical practice [23, 24]. Moreover, the FC approach cultivates high-order cognitive abilities and improves students’ skills, which can be attributed to students being encouraged to utilize their knowledge to solve specific problems and to absorb new ideas through debate or discussion [14, 25]. Notably, the baseline performance between both groups before intervention was comparable. Collectively, the CBL/FC approach combines the advantages of the CBL and FC approaches and improves the students’ ability to transition knowledge from textbooks to real-world clinical settings.

Interestingly, the students in the fifth-year grade obtained higher scores in clinical case scenarios in both the CBL/FC group and the LBT group, while they scored lower in the general knowledge test. This result may be attributed to the students in grade 5 having obtained more experience from their clinical rotations, as they received training in other departments. Meanwhile, students in Grade 4 were still studying clinical medicine courses, while students in Grade 5 had finished their courses and participated in clinical work [26]. Thus, students in Grade 4 may remember more theoretical knowledge compared to their Grade 5 counterparts, which is critical in scoring higher on the general knowledge test.

Subsequently, feedback was collected from students regarding the CBL/FC approach in nephrology teaching. The assessment of questionnaires revealed that the students gave positive perceptions of the CBL/FC. The students felt that the CBL/FC approach helped them to improve their medical history taking, physical examination, medical record documentation, and clinical reasoning skills, as well as consideration for patients’ welfare. Additionally, the students learned to search academic publications and improved their critical thinking by discussing with their classmates. During the CBL/FC processing, the students developed some essential abilities for their science writing and presenting, which may be applicable to their academic careers. In contrast, the LBT method did not provide much motivation. Previous studies have demonstrated similar outcomes, with students showing greater satisfaction with the CBL approach and the FC approach, reporting that both teaching approaches resulted in a deeper understanding [21, 22, 24, 27]. Intriguingly, several studies found that students gave negative feedback about extra burden and pressure when receiving the CBL approach or the FC approach [21, 28]. However, the students enrolled in the CBL/FC group in the present study showed they did not spend an excessive amount of time on their preparation and felt satisfied with this teaching approach. This may be partly attributed to the study having a longer intervention period and students gradually adapting to this learning mode. Moreover, students can feel their progress when using the CBL/FC approach, thereby creating a positive feedback effect. These findings should encourage teachers to consider using the CBL/FC approach in nephrology education since it is very effective in cultivating students’ abilities without extra pressure.

The present study is the first to evaluate the effectiveness of the CBL/FC approach in nephrology bedside teaching. Moreover, this study carried out a long-term intervention and assessed the effect of the CBL/FC approach in different grades. Nevertheless, the limitations of the present study should be acknowledged. Firstly, the present study did not include the CBL group or the FC group due to the limited number of participants. This limits the conclusion about which approach yields the best teaching efficacy. Secondly, the study was limited to the Department of Nephrology, and teaching approaches are generally somewhat different in various departments, especially between surgery and internal medicine. Thirdly, new assessment systems should be created to evaluate the effectiveness of the CBL/FC approach in detail and accurately. Finally, all students participated in the training in the Nephrology Department for only one month, which did not allow for a crossover study, and might potentially introduce bias in the study.

Conclusions

In conclusion, the CBL/FC approach could be a better option than the traditional LBT approach in nephrology education. The CBL/FC method motivates students to learn and cultivates their problem-solving abilities, as well as clinical skills. Our study suggests that the CBL/FC approach is an effective teaching approach, which may promote new strategies for undergraduate medical education.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1 : The survey used in this study

Supplementary Material 2: The corresponding table for each figure presented in this study

Acknowledgements

We want to thank the participating clinical teachers and students.

Author contributions

Conceptualization: Z.D.C.; Acquisition, analysis, or interpretation of data: B.B.H., L.N.Z., L.W., J.X.W.; Drafting the work: B.B.H.; Supervised the entire project: Z.D.C. All authors reviewed the manuscript.

Funding

This work was supported by the Teaching Reform and Cultivation Project of the Second Clinical Medical College of Zhejiang University (20210209, 20230242), the 2023 General Research Project of the zhejiang Provincial Department of Education (Y202351977).

Data availability

The dataset supporting the conclusions of this article are included within the article.

Declarations

Ethics approval and consent to participate

All participants in this study provided informed consent prior to data collection. The participants were informed that their participation was completely voluntary. This study design was approved by the Institutional Review Board and Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine. The ethics approval number is 2021 − 0209.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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