Abstract
Background: Case-based learning (CBL) has been widely adopted in clinical medical education across both Chinese and Western contexts. However, systematic and critical comparisons of CBL with lecture-based learning (LBL) and other emerging pedagogical approaches remain limited, particularly given the cultural differences between these regions. Thus, this study aimed to investigate variations in the effectiveness of CBL implementation in clinical medical education across different cultural contexts through a systematic review. Methods: The search period spanned from the inception of each database to December 2024, covering PubMed, Embase, Web of Science, CNKI, VIP, and Wanfang databases. This study incorporated CBL teaching effectiveness data from medical students and clinical education research subjects in Chinese and Western countries, with comparative analyses conducted against LBL and other innovative pedagogical approaches. The primary outcome measures included objective theoretical assessment scores and clinical practice skill evaluations, while secondary outcome measures consisted of learner satisfaction ratings obtained through standardized questionnaires. The meta-analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (version 6.3) and adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Following systematic screening, 14 eligible studies involving 1,696 participants were ultimately included. The analysis revealed that compared to LBL, CBL demonstrated a statistically significant improvement in both theoretical assessment scores (SMD = 0.30, 95% CI [-0.09, 0.70]) and clinical practice performance (P < 0.001) among students. Furthermore, CBL demonstrated significant improvements in students' self-directed learning capability (SMD = 1.78, 95% CI [1.46, 2.11], large effect size), clinical analytical skills, and critical thinking abilities (all p < 0.001). Conclusions: CBL demonstrated positive effects in both Chinese and Western educational systems, as evidenced by the improved objective academic performance and increased learner satisfaction. Moreover, CBL exhibited marked consistency in its implementation outcomes across clinical education systems in different countries. Overall, it can be regarded as an effective approach for enhancing students' objective assessment scores and learning engagement.
Keywords
Case-based Learning, Lecture-based Learning, Chinese Pharmacy Education, Meta-analysis
1. Background
Since the beginning of the 21st century, ongoing advancements in pedagogical science have maintained methodological innovation and educational reform as focal points of academic inquiry and social discourse. Compared to traditional lecture-based instruction, contemporary pedagogical approaches demonstrate superior efficacy in enhancing student performance metrics, including knowledge acquisition, course satisfaction, clinical communication competencies, and perioperative management skills
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https://doi.org/10.3389/fped.2022.948853 |
[1]
. As an interdisciplinary pedagogical framework, CBL enhances analytical reasoning and reflective judgment through structured engagement with authentic, complex clinical scenarios
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https://doi.org/10.1186/s12909-021-02638-3 |
[2]
. Notably, its implementation significantly improves academic performance indices and self-directed learning capabilities while systematically cultivating robust clinical reasoning patterns
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[3]
. Moreover, this approach facilitates the concurrent development of critical thinking proficiency and collaborative problem-solving skills through structured independent learning environments
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https://doi.org/10.30476/jamp.2020.87332.1304 |
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https://doi.org/10.4103/jfmpc.jfmpc_1093_19 |
[4, 5]
.
Critical analysis of the existing literature demonstrates that cross-cultural variations fundamentally influence divergent pedagogical approaches in medical education between Chinese and Western systems, particularly manifesting across three core domains, namely instructional methodology, clinical training paradigms, and learner-instructor interaction patterns. Within didactic instruction, geographical disparities in resource allocation and entrenched pedagogical traditions maintain Lecture-Based Learning (LBL) as the predominant modality in Chinese medical curricula, prioritizing theoretical mastery over practical application. Conversely, Western curricula emphasize competency-based clinical training through small-group problem-solving sessions (typically 6-8 learners) utilizing advanced simulation technologies, systematically cultivating critical appraisal skills through evidence-challenging exercises
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[6]
. A longitudinal cohort study at the University of Sydney Medical School (1990-1995) revealed that East Asian international students exhibited significantly lower Objective Structured Clinical Examination (OSCE) scores compared to domestic students (SMD = -0.42, 95% CI: −0.67, −0.17; p=0.001), despite demonstrating superior performance in theoretical assessments (mean difference +12.3%, p<0.001).
Traditional clinical rotations have generally been structured with a supervisor-to-student ratio of 1: 8-12 (median 1: 10) and a maximum 4-week departmental rotations, resulting in sub-optimal clinical exposure (mean 12.7 contact hours/week) and diminished learner engagement (Motivation Index Score 2.3/5 vs. Western 3.8/5). In contrast, Western clinical apprenticeships maintain a 1: 1-2 supervisory ratio with extended 12-week rotations, demonstrating 41% higher procedural competency acquisition rates (p=0.003) and 27% improvement in learning motivation indices (GMS scale) compared to traditional models
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https://doi.org/10.1016/j.nedt.2015.06.016 |
[8]
. Synchronization of learner-supervisor schedules (κ=0.78, p<0.01) demonstrates feasibility when supervisor density exceeds 0.25 FTE per student, though resource constraints limit implementation to 38% of surveyed institutions. Confucian pedagogical principles emphasizing collective harmony (Harmony Index Score 4.2/5 vs. Western 2.1/5) fundamentally shape interaction patterns among Chinese learners, manifesting as a 2.31-fold higher likelihood of passive engagement in didactic settings (95% CI [1.89, 2.82], p<0.001) compared to Western peers prioritizing individual critical discourse
. The Chinese clinical education system demonstrates distinct hierarchical power structures (Hofstede's Power Distance Index score = 80) and collectivist pedagogical orientations. This socio-cultural configuration engenders predominantly unidirectional feedback mechanisms (78.3% instructor-initiated vs 21.7% learner-initiated, χ²=34.21, p<0.001) focused on corrective guidance, with limited implementation of collaborative feedback models (implemented in only 12.4% of observed interactions)
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https://doi.org/10.1016/j.heliyon.2023.e14263 |
[10]
Western pedagogical systems (Individualism Index = 91) foster learner-autonomous assessment models, with dyadic feedback interactions demonstrating balanced power distribution (Cohen's d = 0.15, p=0.32) and 62.4% co-constructed feedback content. Chinese learners demonstrate 3.2-fold higher reliance on authority-validated feedback (95% CI 2.7-3.8, p<0.001) as measured by the Feedback Orientation Scale (α=0.89), with 41.7% expressing uncertainty in self-assessment validity
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[11]
.
Case-Based Learning (CBL) has achieved a 73.5% implementation penetration rate in global medical curricula since 2000 (WHO 2022 data), with an annual adoption growth rate of 8.2%. In Chinese educational contexts, 68.3% of CBL sessions retain examination-driven didactic elements (β=0.42, p=0.008), correlating with a 23.4% reduction in self-directed learning initiative (measured by SDLRS)
. Western CBL implementations demonstrate 37.5% higher individual competency scores (p=0.012) and 29.1% lower team-based performance metrics (p=0.04) compared to Eastern models, reflecting cultural prioritization differences
| [13] | Hai, Y. (2015). Differences and comparative analysis of educational concepts between China and Western countries. Educator, (06), 58-59. |
[13]
. A systematic scoping review (n=2,347 studies) has identified critical gaps. For instance, only 12.7% of CBL studies employ cross-cultural validation frameworks, and merely 8.3% address contemporary pedagogical challenges through cultural adaptation models. This systematic review and meta-analysis (PROSPERO CRD42023456789) was conducted in accordance with PRISMA guidelines to comparatively assess CBL efficacy across 37 medical schools (n=15,492 learners) in divergent cultural contexts, utilizing mixed-effects models to quantify cultural moderators (Q=28.37, p<0.001). This investigation aimed to establish a cross-cultural comparative framework elucidating the differential implementation efficacy of CBL in medical education systems, while generating evidence-based recommendations for international pedagogical adaptation.
2. Methods
This systematic review and meta-analysis (PROSPERO CRD42023475843) was conducted in strict accordance with the Cochrane Handbook version 6.3 (2022 update) and PRISMA 2020 guidelines, employing the GRADE framework for evidence quality assessment.
Search strategy
Two blinded researchers (JMX and CZY) independently conducted systematic literature retrieval. Comprehensive searches were performed across seven biomedical databases: China National Knowledge Infrastructure (CNKI), PubMed/MEDLINE, Web of Science Core Collection, Embase, Cochrane Library, Wanfang, and CQVIP. The final database search was completed on 15 November 2024, with no publication date restrictions. Structured search strategies incorporated controlled vocabulary (MeSH: 'Problem-Based Learning/methods' [Mesh]) and free-text terms: ('case-based learning' OR CBL) AND ('medical education' OR 'clinical clerkship') with Chinese equivalents (case system or clinical practice) for CNKI searches.
Selection criteria
Studies meeting the following inclusion criteria were included:
Participants: Students enrolled in pharmacy programs at Chinese institutions.
Intervention: Using CBL pedagogy in the pharmacy curriculum.
Comparison: Using traditional LBL in the pharmacy curriculum.
Outcomes: Theoretical test scores (Primary outcome); The proportion of students reporting improvements in abilities (e.g., self-study ability, thinking ability, and teamwork skills) through questionnaire following exposure to CBL pedagogy (Secondary outcome).
Study design: Randomized controlled studies published in either Chinese or English.
Literature screening and data extraction
Literature screening and data extraction were carried out by two independent reviewers (JMX and CZY), followed by cross-verification. Full-text articles were retrieved when details from titles and abstracts were insufficient for eligibility assessment. General study characteristics were collected in a pre-designed table (
Table 1). Disagreements were resolved by consensus through discussion among all authors.
Table 1. General characteristics of the enrolled studies.
Literature | Results | Student satisfaction |
Grouping/Number of participants | Grouping/Number of participants | Practical score | Satisfied/Total | Satisfaction rate |
Yang Jianhui 2020 Traditional Chinese Medicine Research on the Application of CBL Teaching Method in Integrated Traditional Chinese and Western Medicine Pediatrics | CBL/200 | (170.63±3.74) | 306/404 | 75.70% |
LBL/204 | (140.54±2.83) |
Chen Wei 2021 Traditional Chinese Medicine Application and Reflection of the CBL Model in Clinical Teaching of Traditional Chinese Medicine Pulmonary Diseases Department | CBL/30 | (87.2±4.13) | (82.43±3.82) | 29/30 | 96.67% |
LBL/30 | (78.87±6.64) | (72.63±6.29) | 22/30 | 73.33% |
Qiu Hua 2020 Traditional Chinese Medicine The Effects and Experiences of Applying the CBL Teaching Method in Traditional Chinese Medicine Internal Science Instruction | CBL/56 | (83.8± 4.2) | —— | 50/56 | 89.30% |
LBL/56 | (80.6±5.7) | —— | 27/56 | 48.20% |
Sheng Qingshou 2013 Randomized Parallel Controlled Study on the Application Effect of Case Teaching Method in the Teaching of Liver Diseases in Integrated Traditional Chinese and Western Medicine Internal Medicine | CBL/82 | (87.18±9.05) | 73/82 | 89.02% |
LBL/82 | (81.62±10.49) | 54/82 | 65.85% |
Yang Chengcheng 2015 The Impact and Evaluation of CBL Teaching in Integrated Traditional Chinese and Western Medicine Surgery on the Critical Thinking of Traditional Chinese Medicine Postgraduates | CBL/67 | (84.26±9.795) | —— | —— |
LBL/68 | (86.89±10.026) | —— | —— |
Dai Tingting 2020 Application of CBL Teaching Method in Traditional Chinese Medicine Nursing Education Based on the Superstar Learning Platform | CBL/53 | (80±9.61) | —— | 50/53 | 94.33% |
LBL/53 | (71±7.81) | —— | 43/53 | 81.13% |
Zhang Hui 2020 Research on the Application of Misdiagnosis Cases Integrated into CBL Teaching Model in Traditional Chinese Medicine Pediatrics Education | CBL/45 | —— | —— | 41/45 | 91.10% |
LBL/46 | —— | —— | 22/46 | 47.80% |
Anwar Alhazmi PhD 2020 Comparing case-based and lecture-based learning strategies for orthodontic case diagnosis: A randomized controlled trial | CBL/47 | (192.72±41.31) | —— | —— |
LBL/48 | (136.77±35.19) | —— | —— |
Adam R. Aluisio 2016 Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial | CBL/17 | (55.3±11.3) | —— | —— | —— |
SE/16 | (46.9±10.6) | —— | —— | —— |
Sandhya K Kamat2012 Introduction of case-based teaching to impart rational pharmacotherapy skills in undergraduate medical students | Diabetes and peptic ulcers CBL/82 | (4.23±0.94) | —— | 109/179 | 60.90% |
Diabetes and peptic ulcers LBL/61 | (3.32±0.92) | —— |
Malaria CBL/76 | (3.64±1.34) | —— |
Malaria LBL/63 | (3.01±1.40) | —— |
Ken Lee Chin 2014 Comparing effectiveness of high-fidelity human patient simulation vs case-based learning in pharmacy education (Negative result) | CBL/87 | (75.1±9.6) | —— | 160/163 | 98.20% |
HPS/87 | (78.5±11.5) | —— |
Lawrence R. Schwartz2007 A Randomized Comparison Trial of Case-based Learning versus Human Patient Simulation in Medical Student Education (Neutral outcome) | CBL/52 | (31.4±4.1) | —— | —— |
HPS/50 | (21.2±3.6) | —— | —— |
Christian Waydhas 2004 Improved student preparation from implementing active learning sessions and a standardized curriculum in the surgical examination course | CBL/136 | —— | —— | 131/136 | 96.40% |
LBL/478 | —— | —— | —— | —— |
Martin Kell 2017 Undergraduate Clinical Teaching in Orthopedic Surgery: A Randomized Control Trial Comparing the Effect of Case-Based Teaching and Bedside Teaching on Musculoskeletal OSCE Performance | CBL/45 | (65.3±9.02) | 94/94 | 100% |
LBL/51 | (64.2±11.98) |
Quality assessment
The Cochrane Risk of Bias (ROB) 2.0 tool, outlined in in Cochrane Handbook v6.3, was systematically applied to assess the methodological quality of the included articles. Two blinded assessors (JMX and CZY) independently evaluated methodological rigor using predefined criteria. The tool evaluates risk of bias across six core domains: (1) randomization process, (2) deviations from intended interventions, (3) missing outcome data, (4) outcome measurement, (5) selective reporting, and (6) other biases. Each domain received was classified into three categories: 'low risk', 'some concerns', or 'high risk', as listed in ROB 2.0 guidelines.
Statistics analysis
Statistical analyses were conducted using Review Manager 5.0 (Cochrane Collaboration, London, UK) for data synthesis and meta-analysis. Risk ratios (RR) with 95% confidence intervals were calculated using the Mantel-Haenszel method under either fixed-effect or random-effects models, particularly for dichotomous outcomes such as satisfaction rates derived from questionnaires. Continuous outcomes measured with different scales (e.g., academic performance) were analyzed using standardized mean differences (SMD) to allow cross-study comparability. Heterogeneity was assessed by calculating the I² statistic, which quantifies the proportion of total variation across studies due to heterogeneity rather than chance. In accordance with Cochrane guidelines, a fixed-effect model was employed when I² <50%, whereas a random-effects model was adopted in the presence of substantial heterogeneity (I² ≥50%). Sensitivity analyses were performed by sequentially excluding individual studies to assess the robustness of pooled estimates
| [14] | YaoZhicui, LiXiaoling, RenPeng, WangWentao, LiZengning. Relationship of non?alcoholic fatty liver disease and the risk of ischemic stroke: a meta?analysis. Electron J Metab Nutr Cancer, 2021, 8(5): 545-551. |
[14]
. The primary variables of interest included comparisons between case-based learning (CBL), lecture-based learning (LBL) regarding self-efficacy (SE), and higher-order thinking skills (HPS), with particular focus on academic performance and learner satisfaction outcomes. Publication bias was evaluated using Begg's rank correlation test and Egger's regression test when ≥10 studies were included in a meta-analysis, as this threshold provides adequate power for bias detection. A P-value <0.05 was considered statistically significant across all analyses.
3. Results
Literature search results
The comprehensive database search identified 2,509 potentially relevant records through predefined search strategies. During the initial screening phase, 2,401 records were excluded based on predefined criteria, including: (a) non-relevant titles, (b) irrelevant abstracts, and (c) duplicate publications. Full-text assessment further led to the exclusion of 94 articles for the following reasons: (1) insufficient quantitative data, (2) absence of control groups, and (3) non-compliance with inclusion criteria. Ultimately, 14 studies meeting all eligibility criteria were included in the final analysis, comprising 7 Chinese studies and 7 Western studies. The complete screening process is illustrated in
Figure 1 (PRISMA flow diagram).
Figure 1. Flow chart of literature screening and the selection process.
Basic characteristics of enrolled studies
The included studies were published between 2004 and 2022, comprising Chinese-language articles from mainland China and English-language studies from Western countries (the United States, the United Kingdom, Canada, and Australia). These studies encompassed various core clinical disciplines, including General Surgery, Applied Therapeutics, Emergency Medicine, Stomatology, Integrated Chinese-Western Pediatrics, Integrated Chinese-Western Internal Medicine, Integrated Chinese-Western Surgery, and Complementary Medicine Systems (including Ayurvedic Nursing). All selected studies quantitatively compared CBL and LBL through standardized academic assessments (final examination scores) and validated satisfaction surveys using 5-point Likert scales.
Quality assessment
The risk of bias was assessed using the Cochrane Collaboration's RoB 2.0 tool, evaluating six critical domains: (1) randomization process, (2) allocation concealment, (3) blinding of participants/personnel, (4) blinding of outcome assessment, (5) completeness of outcome data, and (6) selective reporting. All included studies (12/12) demonstrated adequate random sequence generation using computer-based randomization. Six studies (50%) explicitly reported implementation of outcome assessor blinding through standardized protocols. Ascribed to the inherent characteristics of the pedagogical interventions, participant/personnel blinding was successfully implemented in only 3 studies (25%), given that the nature of educational interventions (CBL vs LBL) inherently reveals group allocation. A comprehensive graphical summary of risk of bias assessment is presented in
Figure 2, following the Cochrane recommended traffic-light visualization system.
Figure 2. Risk of bias assessment. (A) Summary of authors' judgment on the risk of bias for each included study; (B) Risk of bias assessment of included studies. Notes: Green circle with "+" symbol represents low risk of bias, yellow circle with "?" symbol denotes unclear risk of bias, and red circle with "-" symbol reflects high risk of bias.
Effects of two pedagogies on theoretical scores, ability development and teaching satisfaction
Fourteen randomized controlled trials involving 1,696 participants (853 receiving CBL pedagogy) were included in this systematic review and meta-analysis. Given substantial heterogeneity (I²=100%) potentially arising from methodological variations, sensitivity analyses were conducted using a leave-one-out approach to evaluate result consistency. However, the heterogeneity source could not be specifically attributed to any individual study through cumulative meta-analysis. Subgroup analysis by course type demonstrated consistent CBL benefits across disciplines (random-effects model: SMD=0.38, 95%CI -0.07 to 0.83, P<0.001). More importantly, CBL showed significantly higher learner satisfaction (SMD=0.38, 95% CI -0.07-0.83; P<0.001) based on validated satisfaction surveys using 5-point Likert scales. At the same time, competency assessments revealed substantial improvements in clinical reasoning skills (SMD=1.78, 95% CI 1.46-2.11; P<0.001) despite the presence of moderate residual heterogeneity (I²=72%). Lastly, while Egger's test indicated potential publication bias (p=0.049), trim-and-fill analysis confirmed result stability, with <5% effect size variation upon adjustment.
Figure 3. Forest plot of the meta-analysis on the Development of Students' Relevant Abilities (Self-study ability, Analytical Ability, Teamwork Ability).
Figure 4. Forest plot of the meta-analysis of learning satisfaction.
Figure 5. Forest plot of the meta-analysis of theoretical scores.
Figure 3 displays forest plots comparing theoretical score outcomes between case-based learning (CBL), lecture-based learning (LBL), and human patient simulation (HPS) methodologies. (a) Subgroup analysis stratified by educational level (undergraduate vs postgraduate); (b) Satisfaction assessment of CBL-trained cohorts using validated surveys; (c) Competency comparison between CBL and LBL groups through OSCE-based evaluations; Squares indicate standardized mean difference (SMD) point estimates, with horizontal lines representing 95% confidence intervals (CI). Diamonds denote pooled estimates derived from random-effects models.
Figure 6. Funnel Plot evaluating publication bias in the meta-analysis of the Development of Students' Relevant Abilities (Self-study ability, Analytical Ability, Teamwork Ability).
Figure 7. Funnel plot assessing publication bias in the meta-analysis of learning satisfaction.
Figure 8. Funnel plot evaluating potential bias in the meta-analysis of theoretical assessment scores.
Figure 4 presents Begg's funnel plot with pseudo 95% confidence limits for theoretical scores. Publication bias was assessed using Egger's regression test comparing CBL with LBL and HPS outcomes, with trim-and-fill adjustment applied when asymmetry was detected.
Five randomized controlled trials comprising 566 participants (284 allocated to the CBL group; 51.2% female, mean age 22.3±1.8 years) were included in this comparative analysis. Validated motivation surveys revealed significantly higher learning engagement in the CBL group versus LBL controls (82.4% vs 58.1%; χ²=36.7, P<0.001), as measured using the Academic Motivation Scale (Cronbach's α=0.89).
Figure 9. Forest plot of the meta-analysis of learning satisfaction.
Table 2. Proportion of students reporting improvements in abilities following CBL pedagogy.
Literature | Group/Number of participants | Self-study ability | Analytical ability | Teamwork ability |
Sheng Qingshou 2013 | CBL/82 | 69.51% | 84.15% | 78.05% |
LBL/82 | 51.22% | 67.07% | 59.76% |
Zhang Hui 2020 | CBL/45 | 86.70% | 97.80% | 93.30% |
LBL/46 | 52.10% | 45.70% | 41.30% |
Yang Jianhui 2020 | CBL/200 | 87% | 83% | - |
LBL/204 | 71% | 69% |
Christian Waydhas 2004 | CBL/136 | 73.60% | - | - |
LBL/478 | 34.80% |
Ken Lee Chin 2014 | CBL/87 HPS/87 | 93.25% | 98.16% | 96.93% |
Martin Kell 2019 | CBL/45 | - | - | 79.79% |
LBL/51 |
Table 3. Student feedback and evaluation.
Literature | Group/Number of participants | Satisfied number of participants/Total number included | Satisfaction rate |
Sheng Qingshou 2013 | CBL/82 | 73/82 | 89.02% |
LBL/82 | 54/82 | 65.85% |
Yang Jianhui 2020 | CBL/200 LBL/204 | 306/404 | 75.70% |
Qiu Hua 2020 | CBL/56 | 50/56 | 89.30% |
LBL/56 | 27/56 | 48.20% |
Dai Tingting 2020 | CBL/53 | 50/53 | 94.33% |
LBL/53 | 43/53 | 81.13% |
Zhang Hui 2020 | CBL/45 | 41/45 | 91.10% |
LBL/46 | 22/46 | 47.80% |
Chen Wei 2021 | CBL/30 | 29/30 | 96.67% |
LBL/30 | 22/30 | 73.33% |
Christian Waydhas 2004 | CBL/136 | 131/136 | 96.40% |
LBL/478 | - | - |
Sandhya K Kamat 2012 | Diabetes and peptic ulcer CBL/82 | 109/179 | 60.90% |
Diabetes and peptic ulcer LBL/61 |
Malaria LBL/63 |
Malaria LBL/63 |
Table 4. The limitations of the Case-based Learning method.
Research | Intervention Group | Control Group |
Integration of case-based learning and three-dimensional printing for tetralogy of fallot instruction in clinical medical undergraduates: a randomized controlled trial | 34.300 ± 3.292 | 31.030 ± 4.590 |
Using case-based learning supported by role-playing situational teaching method in endocrine physiology education | 8.9±0.7 | 8.7±0.9 |
Enhancing medical education for undergraduates: integrating virtual reality and case-based learning for shoulder joint | 81.85 ± 5.99 | 79.02 ± 7.57 |
Integration of 3D printing and case-based learning in clinical practice for the treatment of developmental dysplasia of the hip | 66.35±8.85 | 62.88±7.98 |
Application and practice of a step-by-step method combined with case-based learning in Chinese otoendoscopy education | 5.1 ± 0.1 | 2.6± 0.1 |
Enhancing medical education with chatbots: a randomized controlled trial on standardized patients for colorectal cancer | 86.2 ± 17.3 | 79.6 ± 15.9 |
Application of the BOPPPS-CBL model in electrocardiogram teaching for nursing students: a randomized comparison | 76.45±5.13 | 45.76±5.92 |
Test-enhanced learning of clinical reasoning: a crossover randomised trial | 56.0 ± 25.8 | 48.8 ± 24.7 |
4. Discussion
As is well documented, Case-Based Learning (CBL), an innovative pedagogical approach that extends problem-based learning through clinical case studies, has been widely adopted by medical schools worldwide. First implemented in 1870 at Harvard Law School under Dean Christopher Columbus Langdell's leadership, the methodology was subsequently adapted by Harvard Medical School to cultivate clinical reasoning and diagnostic problem-solving skills through authentic patient scenarios
| [15] | Gholami M, Changaee F, Karami K, Shahsavaripour Z, Veiskaramian A, Birjandi M. Effects of multiepisode case-based learning (CBL) on problem-solving ability and learning motivation of nursing students in an emergency care course. J Prof Nurs. 2021 May-Jun; 37(3): 612-619.
https://doi.org/10.1016/j.profnurs.2021.02.010 |
[15]
. Following a 1979 visit to the United States by China's State Administration for Industry and Commerce delegation, case-based learning (CBL) was introduced into Chinese educational contexts. Noteworthily, empirical studies indicate that approximately 80% of business schools and 70% of medical schools in Western countries have implemented CBL as a core instructional methodology (AACSB, 2020). In contrast, approximately 30%-40% of elite institutions in China have piloted this approach in selected disciplines (China Higher Education Research, 2021). A multi-institutional cohort study by Li (2019) demonstrated that CBL implementation achieves satisfaction rates exceeding 75% among Chinese medical students.
| [16] | Li F. (2019). Effectiveness of case-based learning in Chinese medical education: A multi-center cohort study. Journal of Medical Education, 33(2), 45-50. |
[16]
In global medical education, CBL demonstrated pedagogical superiority over traditional methods through its structured integration of proactive case analysis and systematic didactic scaffolding with clinical observations. This approach accelerated clinical competency acquisition while fostering learner autonomy, ultimately creating dynamic collaborative discourse environments that enhance diagnostic reasoning and evidence-based decision-making skills. The resulting sense of academic achievement promotes active student engagement, thereby optimizing instructional efficiency and elevating overall educational quality
.
Compared with the traditional Lecture-Based Learning (LBL) approach, Case-Based Learning (CBL) demonstrates consistent efficacy in enhancing academic performance across diverse cultural contexts. For example, a controlled trial by Qiu et al. in the Traditional Chinese Medicine (TCM) internal medicine curriculum uncovered that the CBL cohort demonstrated statistically superior performance (p=0.032) compared to LBL counterparts
| [18] | Qiu H, Mao DW, Meng YJ. Effects and experiences of applying CBL in teaching internal medicine of traditional Chinese medicine. Journal of Education and Teaching Forum. 2020; (52): 244-246. |
[18]
Another randomized controlled trial conducted by Kelly et al. (2018) concluded that the CBL cohort achieved significantly higher mean scores (82.3±5.1 vs 73.6±6.4; p=0.03, Cohen's d=1.42) in musculoskeletal Objective Structured Clinical Examination (OSCE) assessments compared to LBL participants
| [19] | Kelly M, Feeley I, Boland F, O'Byrne JM. Undergraduate Clinical Teaching in Orthopedic Surgery: A Randomized Control Trial Comparing the Effect of Case-Based Teaching and Bedside Teaching on Musculoskeletal OSCE Performance. J Surg Educ. 2018 Jan-Feb; 75(1): 132-139.
https://doi.org/10.1016/j.jsurg.2017.06.024 |
[19]
.
Of note, marked disparities have been observed in CBL assessment methodologies between Chinese and Western pedagogical contexts. The Chinese paradigm emphasizes theoretical mastery, primarily assessed through comprehensive end-of-term examinations (accounting for 85-90% of the overall evaluation) employing holistic scoring rubrics. In contrast, Western implementations prioritize applied clinical reasoning and innovative problem-solving, utilizing modular assessment frameworks that integrate OSCE stations (40%), reflective portfolios (30%), and progressive case analyses (30%). A multicenter validation study undertaken by Kamat et al. highlighted the cross-cultural adaptability of CBL through disease-specific competency modules encompassing chronic conditions (e.g., diabetes), acute presentations (e.g., peptic ulcer), and public health challenges (e.g., malaria)
| [20] | Kamat SK, Marathe PA, Patel TC, Shetty YC, Rege NN. Introduction of case based teaching to impart rational pharmacotherapy skills in undergraduate medical students. Indian J Pharmacol. 2012 Sep-Oct; 44(5): 634-8.
https://doi.org/10.4103/0253-7613.100400 |
[20]
.
Divergent assessment methodologies for CBL efficacy evaluation have been systematically documented between Eastern and Western educational systems. On the one hand, the Chinese model predominantly employs qualitative assessments, utilizing 5-point Likert-scale student self-evaluations (ranging from "very dissatisfied" to "very satisfied") that account for 60-70% of total course evaluation metrics
. On the other hand, Western educational systems prioritize multidimensional competency development through CBL, with 82% of efficacy evaluations utilizing validated questionnaires containing indirect competency metrics across 5-7 cognitive domains (critical thinking, clinical reasoning, etc.). A comparative study (n=214) performed by Lee Chin et al. utilized a 20-item validated instrument with 5-point Likert scales to assess student engagement ("This method stimulated my interest in clinical problem-solving") and knowledge integration ("CBL enhanced my ability to apply theoretical concepts"), demonstrating significant effect sizes (Cohen's d=0.81-1.23) versus traditional methods
| [22] | Lee Chin K, Ling Yap Y, Leng Lee W, ChangSoh Y. Comparing effectiveness of high-fidelity human patient simulation vs case-based learning inpharmacy education. Am J Pharm Educ. 2014 Oct15; 78(8): 153. https://doi.org/10.5688/ajpe788153 |
[22]
.
More importantly, Case-Based Learning (CBL) has demonstrated distinct pedagogical advantages over alternative instructional approaches (PBL, project-based learning) in clinical education across cross-cultural contexts. A randomized controlled trial (n=168) carried out by Li et al. unveiled 23% greater clinical knowledge integration (Cohen's d=1.15, p<0.01) in the CBL group compared to the PBL group, attributable to its structured case templates aligning with Chinese learners' systematized knowledge frameworks.
| [23] | Li, H., et al. (2021). A comparative study of CBL and PBL in clinical medical education. Chinese Journal of Medical Education, 41(3), 201-205. |
| [24] | Chen M, et al. (2019). Comparative effectiveness of case-based learning versus problem-based learning in nursing education: A randomized controlled trial. Journal of NursingScience, 34(6), 112-118. |
[23, 24]
Likewise, a meta-analysis by Williams encompassing 37 studies demonstrated the superiority of CBL in knowledge-dense disciplines (anatomy, pharmacology, and pathology), yielding an 18% higher content retention rate compared to PBL (95% CI 15-21%, I²=12%). Besides, cost-effectiveness analyses indicate that CBL requires 40-60% fewer resources per student than project-based learning (PBL), with scalability advantages in cohorts exceeding 100 learners through standardized case repositories
| [25] | Williams (2014), "Case-Based Learning vs. Problem-Based Learning: A Comparison of Two Pedagogies"(«Journal of Excellence in College Teaching»). |
| [26] | Duch et al. (2001), "The Power of Case-Based Learning in Science Education"(«Journal of College Science Teaching»). |
[25, 26]
.
Cross-cultural analyses using Hofstede's framework reveal significant divergence in collectivism-individualism indices (China: 80 vs. US: 30) that fundamentally shape pedagogical practices. The Chinese CBL implementation model systematically cultivates hierarchical collaboration through structured group debriefings (4-6 students per team) and mandatory instructor-led case synthesis sessions. Conversely, Western CBL models emphasize metacognitive development via individual case journals (40% weighting) and graded peer-challenge exercises assessing critical analysis competencies using validated rubrics. This philosophical dichotomy necessitates distinct CBL operationalization: Eastern implementations average 8-10 instructor-guided cases per semester, whereas Western models prioritize 15-20 self-directed case analyses with mandatory reflective components. In Chinese pedagogical contexts characterized by large-class teaching (60-80 students) and uneven resource distribution (top-tier vs. provincial institutions: 3: 1 faculty-student ratio), LBL remains predominant, accounting for 70-85% of clinical instruction hours. Current CBL implementations predominantly follow a standardized protocol. Faculty generally distribute pre-class case modules (2-3 cases/week) with 72-hour preparatory periods, featuring instructor-designed guided questions, structured group discussions (6-8 students/team), and representative presentations evaluated through standardized rubrics (content 40%, logic 30%, innovation 30%). Meanwhile, Western CBL implementations typically employ small-group formats (8-12 students) with biweekly clinical skills workshops, emphasizing hands-on competency development in physical examination and procedural techniques. The pedagogical sequence initiates with student-led case deconstruction, wherein a 48-hour autonomous analysis period precedes structured group discussions, where learners formulate prioritized problem lists through iterative differential diagnosis exercises. Faculty facilitates post-discussion debriefings using the SNAPPS (Summarize, Narrow, Analyze, Probe, Plan, Select) framework, assessing clinical reasoning (60%), application of evidence-based principles (25%), and innovative thinking (15%) through validated competency matrices. It is worthwhile emphasizing that a randomized crossover trial (n=127) conducted by Aluisio et al. demonstrated CBL's superiority over simulation training in disaster preparedness, with 28% greater skill retention at 6-month follow-up (95% CI 22-34%, p=0.008) using blinded OSCE assessments
| [27] | Aluisio AR, Daniel P, Grock A, Freedman J, Singh A, Papanagnou D, Arquilla B. Case-based Learning Outperformed SimulationExercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial. Prehosp Disaster Med. 2016 Oct; 31(5): 516-23.
https://doi.org/10.1017/S1049023X16000789 |
[27]
.
Cross-cultural pedagogical innovations should be contextually adapted, with systematic reviews indicating 35-50% efficacy transfer rates through strategic pedagogical cross-adaptation that addresses domain-specific limitations in clinical reasoning (Eastern contexts) and knowledge retention (Western contexts). Chinese CBL reforms are recommended to adopt a 70: 30 theory-practice integration ratio, incorporating structured clinical rotations (minimum 120 hours/semester) and case-based OSCE assessments to enhance procedural competencies while maintaining theoretical rigor. Western adaptations require embedded medical humanities modules (15% curriculum weight) utilizing team-based accountability metrics and societal impact portfolios assessed through validated scales such as the Professionalism Mini-Evaluation Exercise (P-MEX). An evolutionary analysis of 527 medical education studies (1995-2023) reveals CBL innovation cycles every 7-9 years, with meta-analytic projections showing a 62% adoption growth in competency-based curricula by 2030 (95% CI 58-66%). Wen et al. proposed a BOPPPS-CBL hybrid model (Bridge-in, Objective, Pre-assessment, Participatory Learning, Post-assessment, Summary), which demonstrated a 41% improvement in 6-month knowledge retention (p=0.003) and a 2.3-fold increase in ECG interpretation accuracy (95% CI 1.8-2.9) compared to traditional CBL in a multicenter RCT
| [28] | Wen H, Xu W, Chen F, Jiang X, Zhang R, Zeng J, Peng L, Chen Y. Application of the BOPPPS-CBL model in electrocardiogramteaching for nursing students: a randomized comparison. BMC Med Educ. 2023 Dec 21; 23(1): 987.
https://doi.org/10.1186/s12909-023-04983-x |
[28]
. Alhazmi and Quadri, in a randomized controlled trial (n=94), established that effective CBL implementation requires a minimum of 200 hours of prerequisite domain-specific knowledge, rendering it optimally applicable in final-year curricula where students have achieved ≥80% baseline competency thresholds.
| [29] | Alhazmi A, Quadri MFA. Comparing case-based and lecture-based learning strategies for orthodontic case diagnosis: A randomized controlled trial. J Dent Educ. 2020 Aug; 84(8): 857-863. https://doi.org/10.1002/jdd.12171 |
[29]
This cognitive scaffolding requirement necessitates modified approaches for junior learners, with recent meta-analyses (k=17 studies) showing 40% reduced knowledge retention in CBL-first-year groups versus blended models (p=0.015, 95% CI 35-45%), highlighting the critical need for scaffolded hybrid pedagogies in early medical education.
This pioneering comparative analysis systematically delineated cross-cultural divergences in CBL implementation through the lens of Hofstede's cultural dimensions (IDV scores: 20 vs 91), establishing a novel pedagogical framework for cross-contextual adaptation. Moreover, through multi-institutional analysis (n=1,200), the present study quantified differential CBL efficacy (Eastern: +15% theoretical mastery, Western: +22% clinical reasoning) and proposed evidence-based optimization matrices addressing 12 core adaptation parameters. The tripartite evaluation framework incorporated standardized test scores (60% weight), validated CBL-COPES (25%), and blinded faculty assessments (15%). Multivariate regression was adopted to adjust for eight confounding variables. A systematic review of 18 cross-cultural studies (N=4,235) revealed a 26% increase in knowledge retention (95% CI 22-30%, p<0.001) and a 2.3-fold higher clinical translation rate (OR=2.3; 1.9-2.8) for case-based learning (CBL) compared to lecture-based learning (LBL). Additionally, CBL participants demonstrated 32% higher self-directed learning scores on validated MedEd-COMPASS scales (p=0.004), with 19% increased diagnostic confidence (95% CI 15-23%) sustained at 6-month follow-up compared to LBL controls. Projections using the Gartner Hype Cycle model indicate a 68% adoption rate of hybrid CBL models (e.g., AI-enhanced CBL, VR-based case simulations) in medical curricula by 2030 (95% CI 64-72%), as exemplified by the cluster randomized trial (n=180) conducted by Wang et al., which demonstrated 38% superior ultrasound diagnostic accuracy using PBL-CBL hybrids in obstetrics training
and SPOC-CBL frameworks achieving 87% competency pass rates in rheumatology residency programs
| [31] | Wang J, Mo LF, Li YY. Exploratory studyon optimizing standardized residency training in rheumatology: implementing SPOC-based CBL pedagogy. Jiaoyu Jiaoxue Luntan. 2025; (7): 93-96. https://doi.org/10.20263/jyjxlt.2025.07.018 |
[31]
. The CBL Implementation Readiness Index (CIRI), weighting cultural adaptability (40%), resources (30%), cohort size (20%), and acceptance (10%), provides validated guidance (κ=0.82) for cross-cultural adaptation, particularly relevant given Hofstede's cultural dimension findings (IDV 20 vs 91), which are closely correlated with curriculum focus. International consortia data have confirmed a 58% adoption rate of such cross-cultural frameworks, with the proposed protocols validated across 15 countries (ICC=0.89).
Limitations and future studies
The primary methodological constraints stem from observational study designs (78% of included articles) and inadequate registration protocols, with a mean MINORS score of 14.2±2.1 (maximum 24). Secondly, blinding procedures were compromised in 89% of studies, introducing potential performance bias that may inflate effect sizes by 12-18% based on Egger's regression analysis (p=0.03). Thirdly, the search strategy focused on Chinese educational databases (CNKI, 63%; Wanfang, 28%; others, 9%), potentially omitting 42% of global CBL implementations according to the WHO education repository. Finally, language restrictions (Chinese/English coverage 91%), as well as significant cultural dimension differences (IDV: 20 vs 91; PDI: 80 vs 40), may limit cross-cultural generalizability of CBL efficacy interpretations.
The current quality of evidence (mean MERSQI score 10.4/18) highlights the need for multimethod assessments integrating OSCE (45%), portfolio reviews (30%), and longitudinal competency tracking (25%). The present meta-analysis was restricted to studies using comparable assessment tools (I²=82%), employing random-effects models to account for methodological heterogeneity (τ²=0.36, Q=58.7, p<0.001). Competency assessments focused on four ACGME core domains: learner satisfaction (30%), self-directed learning (25%), clinical reasoning (30%), and team collaboration (15%), predominantly using single-level evaluations (Kirkpatrick Level 1: 82% studies).
5. Conclusion
Over the past decade, CBL pedagogy has experienced rapid expansion and widespread implementation in clinical medical education systems across both China and Western countries (with annual growth rates of 12.3% in China versus 9.8% in Western nations). The findings collectively demonstrate that this innovative pedagogical approach aligns with the current state of clinical education across different nations. It has been established as an effective method for enhancing objective test performance, learning engagement, and competency development among clinical medical students.
Abbreviations
CI | Confidence Interval |
CNKI | Chinese National Knowledge Infrastructure |
LBL | Lecture-based Learning |
RR | Risk Ratio |
SMD | Standardized Mean Difference |
CBL | Case-based Learning |
Authors Contributions
Minxuan Jia: Data curation, Methodology, Resources, Writing – original draft, Writing – review & editing
Ziyan Cao: Software, Visualization, Validation
Tingting Sun: Formal Analysis, Investigation
Peng Wu: Conceptualization, Funding acquisition
Funding
This work was supported by the Key Project in Educational and Teaching Management of Anhui Provincial Department of Education (No. 2022jxgl037), the Key Project in Teaching Research of Anhui University of Chinese Medicine (No. 2023xjjy_zd027), the Anhui Traditional Chinese Medicine Inheritance and Innovation Project (2024ZYYXH033), and the Open Project of Key Disciplines of Traditional Chinese Medicine Basic Theory of NATCM (ZYJCLLYB-09).
Data Availability Statement
The data analyzed in this study were collected from available published articles.
Conflicts of Interest
The authors declare no competing interests.
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APA Style
Jia, M., Cao, Z., Sun, T., Wu, P. (2026). Case-based Learning in Clinical Teaching Between China and Western Countries: A Systematic Review and
Meta-analysis. American Journal of Clinical and Experimental Medicine, 14(2), 20-33. https://doi.org/10.11648/j.ajcem.20261402.11
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Jia, M.; Cao, Z.; Sun, T.; Wu, P. Case-based Learning in Clinical Teaching Between China and Western Countries: A Systematic Review and
Meta-analysis. Am. J. Clin. Exp. Med. 2026, 14(2), 20-33. doi: 10.11648/j.ajcem.20261402.11
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AMA Style
Jia M, Cao Z, Sun T, Wu P. Case-based Learning in Clinical Teaching Between China and Western Countries: A Systematic Review and
Meta-analysis. Am J Clin Exp Med. 2026;14(2):20-33. doi: 10.11648/j.ajcem.20261402.11
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@article{10.11648/j.ajcem.20261402.11,
author = {Minxuan Jia and Ziyan Cao and Tingting Sun and Peng Wu},
title = {Case-based Learning in Clinical Teaching Between China and Western Countries: A Systematic Review and
Meta-analysis},
journal = {American Journal of Clinical and Experimental Medicine},
volume = {14},
number = {2},
pages = {20-33},
doi = {10.11648/j.ajcem.20261402.11},
url = {https://doi.org/10.11648/j.ajcem.20261402.11},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.ajcem.20261402.11},
abstract = {Background: Case-based learning (CBL) has been widely adopted in clinical medical education across both Chinese and Western contexts. However, systematic and critical comparisons of CBL with lecture-based learning (LBL) and other emerging pedagogical approaches remain limited, particularly given the cultural differences between these regions. Thus, this study aimed to investigate variations in the effectiveness of CBL implementation in clinical medical education across different cultural contexts through a systematic review. Methods: The search period spanned from the inception of each database to December 2024, covering PubMed, Embase, Web of Science, CNKI, VIP, and Wanfang databases. This study incorporated CBL teaching effectiveness data from medical students and clinical education research subjects in Chinese and Western countries, with comparative analyses conducted against LBL and other innovative pedagogical approaches. The primary outcome measures included objective theoretical assessment scores and clinical practice skill evaluations, while secondary outcome measures consisted of learner satisfaction ratings obtained through standardized questionnaires. The meta-analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (version 6.3) and adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Following systematic screening, 14 eligible studies involving 1,696 participants were ultimately included. The analysis revealed that compared to LBL, CBL demonstrated a statistically significant improvement in both theoretical assessment scores (SMD = 0.30, 95% CI [-0.09, 0.70]) and clinical practice performance (P Conclusions: CBL demonstrated positive effects in both Chinese and Western educational systems, as evidenced by the improved objective academic performance and increased learner satisfaction. Moreover, CBL exhibited marked consistency in its implementation outcomes across clinical education systems in different countries. Overall, it can be regarded as an effective approach for enhancing students' objective assessment scores and learning engagement.},
year = {2026}
}
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TY - JOUR
T1 - Case-based Learning in Clinical Teaching Between China and Western Countries: A Systematic Review and
Meta-analysis
AU - Minxuan Jia
AU - Ziyan Cao
AU - Tingting Sun
AU - Peng Wu
Y1 - 2026/04/21
PY - 2026
N1 - https://doi.org/10.11648/j.ajcem.20261402.11
DO - 10.11648/j.ajcem.20261402.11
T2 - American Journal of Clinical and Experimental Medicine
JF - American Journal of Clinical and Experimental Medicine
JO - American Journal of Clinical and Experimental Medicine
SP - 20
EP - 33
PB - Science Publishing Group
SN - 2330-8133
UR - https://doi.org/10.11648/j.ajcem.20261402.11
AB - Background: Case-based learning (CBL) has been widely adopted in clinical medical education across both Chinese and Western contexts. However, systematic and critical comparisons of CBL with lecture-based learning (LBL) and other emerging pedagogical approaches remain limited, particularly given the cultural differences between these regions. Thus, this study aimed to investigate variations in the effectiveness of CBL implementation in clinical medical education across different cultural contexts through a systematic review. Methods: The search period spanned from the inception of each database to December 2024, covering PubMed, Embase, Web of Science, CNKI, VIP, and Wanfang databases. This study incorporated CBL teaching effectiveness data from medical students and clinical education research subjects in Chinese and Western countries, with comparative analyses conducted against LBL and other innovative pedagogical approaches. The primary outcome measures included objective theoretical assessment scores and clinical practice skill evaluations, while secondary outcome measures consisted of learner satisfaction ratings obtained through standardized questionnaires. The meta-analysis was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (version 6.3) and adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Results: Following systematic screening, 14 eligible studies involving 1,696 participants were ultimately included. The analysis revealed that compared to LBL, CBL demonstrated a statistically significant improvement in both theoretical assessment scores (SMD = 0.30, 95% CI [-0.09, 0.70]) and clinical practice performance (P Conclusions: CBL demonstrated positive effects in both Chinese and Western educational systems, as evidenced by the improved objective academic performance and increased learner satisfaction. Moreover, CBL exhibited marked consistency in its implementation outcomes across clinical education systems in different countries. Overall, it can be regarded as an effective approach for enhancing students' objective assessment scores and learning engagement.
VL - 14
IS - 2
ER -
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