Medical education challenges in Mainland China: An analysis of the application of problem-based learning

Figures & data

Figure 1. Flow diagram of study selection.

Table 1. Main characteristics extracted from the included 21 studies.

No.	Study	Population	Setting	Design*	Intervention	Sample size	Findings
1	[25]	Third-year clinical medicine undergraduates	Shandong First Medical University	Single	PBL	294	Of all the three kinds of case scenarios in PBL mode, common disease with typical symptoms cases interspersed with atypical symptoms and rare disease cases scenarios had more positive effects on the self-evaluated performance of students.
2	[26]	Students practiced in the emergency department	Qilu Hospital, Shandong University	Whole	PBL vs LBL	50 vs 48	The clinical emergency PBL teaching method is more prominent in improving the performance of students’ clinical emergency ability, and can more effectively improve students’ theoretical technical operation level, autonomous learning ability, communication ability and communication judgment ability.
3	[27]	Students enrolled in a seven-year program at the College of Stomatology	Shanghai JiaoTong University	Single	PBL, CBL	38	Students who have experienced PBL continue to actively participate in problem-solving and could solve new problems more effectively in the future, which is beneficial for the long-term development of students.
4	[28]	Students practiced in the paediatric department	The First Affiliated Hospital of Bengbu Medical College	Whole	PBL vs LBL	150 vs 150	PBL teaching can effectively improve students’ academic performance, mastery of paediatric knowledge, self-evaluation of comprehensive ability and learning satisfaction.
5	[29]	Nursing student interns studying in the traumatology department	The Affiliated Hospital of Beihua University	Whole	PBL vs LBL	94 vs 93	The application of PBL combined comparative nursing rounds in the teaching of nursing for traumatology is beneficial for a significant improvement in the grasp of theoretical knowledge, operational ability, critical thinking ability, and teaching approval.
6	[30]	Fourth-year clinical laboratory medicine students	Hubei University	Single	PBL vs LBL	66 vs 56	PBL resulted in significantly better theory test scores, better student feedback scores, and clinical performance assessments, and a higher rate of satisfaction among students and teachers.
7	[31]	Third-year undergraduate medical students	Peking University	Whole	PBL	102	Critical thinking disposition positively correlates to a students’ PBL performance. Students with stronger critical thinking perform better in the PBL process and obtain higher scores.
8	[32]	College-level nursing student	Shanxi Medical University	Whole	PBL vs LBL	162 vs 166	The examination scores and self-learning capabilities were significantly higher in the experimental group compared with the control group.The web-based PBL teaching approach appears to be more optimal than traditional teaching methods in a large class-size teaching environment.
9	[33]	Spine surgery postgraduate-year-1 residents	The First Hospital of China Medical University	Single	PBL vs LBL	15 vs 15	The problem and scripting-based learning method can activate spine residents’ prior knowledge and building on existing cognitive frameworks.
10	[34]	Fourth-year undergraduate students studying dental alveolar surgery	China Medical University	Single	PBL vs LBL	42 vs 48	Both PBL graduates and the tutors rated their preparation for clinical practice as higher than those who received traditional lecture-based courses. The PBL integrated dental alveolar surgery may improve preparedness for clinical practice and help undergraduates to develop the desire to collaborate.
11	[35]	Nursing student	School of Zhengzhou Industrial Technology	Whole	PBL vs LBL	64 vs 64	The application of PBL teaching method can play an active role in improving the classroom teaching effect and teaching quality, as well as activating the classroom atmosphere and enhancing the enthusiasm and initiative of students’ participation in class.
12	[36]	Undergraduate students enrolled in clinical pharmacy	College of Pharmacy, Beihua University	Whole	PBL	100	The application of PBL in the clinical pharmacology experiment could improve their learning methods, cultivate their innovative thinking, problem-posing, problem-analyzing and problem-solving capacity, language expression and interpersonal communication capacity, strengthen their team assistance spirit.
13	[37]	College juniors in clinical medicine	West china hospital, sichuan University	Whole	PBL vs LBL	40 vs 40	PBL improved interest in learning, cultivate an ability to study independently, improve communication and analytical skills, and good team cooperation spirit with some shortcomings in systematization of imparting knowledge.
14	[38]	Second-year undergraduate nursing students	Shanghai JiaoTong University	Single	PBL vs LBL	37 vs 39	PBL learning significantly enhanced the critical thinking dispositions of nursing students.
15	[39]	Second-year undergraduate students	Third Military Medical University	Whole	Hybrid-PBL (60% LBL and 40% tutor-less PBL) vs LBL	101 vs 104	Students reported positive effects of hybrid-PBL in terms of additional learning resources, critical thinking, and fun learning experiences.
16	[40]	Fourth-year undergraduate students enrolled in dermatology course	Central South University	Single	Real patient or digital- or paper-form PBL vs LBL	90 vs 30	Compared to those receiving lectures only, PBL participants had better results for written examination, clinical examination and overall performance. Real-patient cases were more effective in helping develop students’ self-directed learning skills than digital- or paper-form cases.
17	[41]	Students attending five-year undergraduate medical program	Lan Zhou University	Whole	PBL vs LBL	54 vs 53	The teaching method of PBL could activate learning enthusiasm and interest, improve problem analysis of students. It also enhanced independent study abilities and learning efficiency, strengthened the teacher–student communication.
18	[42]	Fourth-year students of Stomatology	Shanghai Jiao Tong University	Whole	PBL vs LBL	43 vs 44	PBL courses combined with supervised clinical rotation were shown to improve students’ operative skill, enhance their ability to perform case analysis, and improve their self-confidence.
19	Ma et al. 2012	Third-year undergraduate students in clinical medicine	Guangzhou Medical Collage	Single	Web-PBL vs LBL	31 vs 31	The teaching mode of PBL could improve many comprehensive abilities of students and had obvious long-term effect on application although it had no short-term effect on factual knowledge measured by multiple-choice and short-assay.
20	[43]	Fifth-year undergraduate students enrolled in regional anatomy course	Peking University Health Science Center	Single	PBL vs LBL	83 vs 78	Clinical PBL approach stimulates students’ interest in learning and enhances anatomy education.
21	[44]	Fifth-year students in ophthalmology Courses	The Fourth Affiliated Hospital of China Medical University	Whole	PBL vs LBL	60 vs 30	Students in PBL groups exhibited better performance in the practice procedures and had significantly higher mean results of theoretical and case analysis examination.

PBL: problem-based learning; LBL: lecture-based learning; CBL: case-based learning.

* Single for single curriculum intervention; Whole for whole curriculum intervention.

Table 2. Summary of outcome variables, results, and quality assessment of included studies (single course intervention).

No.	Study	Evaluation tool	Outcome Variables	Results	Study Quality
1	[25]	Four-point rating scale postal questionnaire	Students’ attitudes towards the quality of cases	PBL with rare disease case scenarios were especially beneficial in promoting the integration of knowledge*, learning the frontiers of knowledge** and in improving the ability to collect, re-organise, and analyse information** and critical thinking abilities*.	Moderate
			Self-evaluation on skills and the content of the case scenario sessions	Both CDAS* and RD** case scenarios were especially beneficial to their study and work. CDAS case scenarios were more helpful for developing deeper self-awareness*. RD case scenarios were superior in helping them develop their skills including clinical thinking skills**, interpersonal skills**.
		Students’ comments	N/A	A few students in the RD group complained about spending more time on information retrieval and discussion after classes, most of them expressed positive opinions on the CDAS and RD case scenario sessions.	Weak
2	[27]	Questionnaires	Enhances study interest; b. encourages acquiring knowledge, c. helps to apply theoretical knowledge; d. takes more time; e. promotes teacher‒student Interactions; f. promotes student‒student interactions	Higher in PBL for (d), (f)*; Lower in other items*.	Weak
			Faculty evaluation on same item	Higher in PBL for (b), (d), (f)*; Lower in other items*.
3	[30]	Faculty evaluation	Theory test	Higher in PBL**.	Moderate
			Clinical performance	Higher in PBL***.
		Four-point rating scale postal questionnaires	Observations, challenges, problem-solving ability, and operational ability	All higher in PBL***.	Weak
4	[33]	Five-point Liker scale feedback questionnaire	a.Preparedness; b.performance	Both are higher in PBL*.	Weak
			Students’ satisfaction in a.the assumptions of each proponent, b.achievement of specific learning objectives, c.overall preference for each teaching method, d.the development of operation skills and e.individual judgment.	Higher in PBL for (b), (d), (e); NSD in other item.
		Faculty evaluation	Theoretical examination	NSD	Moderate
5	[34]	Faculty evaluation	Theoretical examination and clinical case analysis	NSD	Moderate
		Ten-point scale questionnaire	The interests in learning and the motivation to cooperate with their classmates	Higher in PBL***.	Weak
		Self rating by telephone interview	Quantitative items for a.the students’ self-perceived preparedness for clinical practice, b.the attitudes and behaviours concerning lifelong learning, c. abilities and willingness to collaborate with other colleagues over the past 3 years.	Higher in PBL for (a)* and (c)***, NSD for (b).	Weak
		SAA	Faculty evaluation on same items	Higher in PBL for (b)* and (c)***, NSD for (a).	Weak
		Open-ended questionnaire	The open-ended question related to how the PBL teaching programme helped the students develop lifelong learning and collaboration abilities.	NSD	Weak
6	[38]	CTDI-CV	Comprehensive evaluation for a. truth seeking, b. open-mindedness, c.analyticity, d. systematicity, e. critical thinking self-confidence, f. inquisitiveness, and g. cognitive maturity during the first possess.	Higher in PBL for (b)*, (f)*, (g)* and the total scores*; NSD in other item.	Moderate
			During the second possess on same item.	Higher in PBL for (b)**, and the total scores*; NSD in other item.
7	[40]	Faculty evaluation	Written examination	All higher in PBL*.	Moderate
			Clinical examination	All higher in PBL**.
		Five-point Likert scale questionnaire	a.Student’s self-evaluation on skills and b. student’s attitude towards the teaching method, quality of cases and the content of the course	Higher in PBL for (a)** and (b)*.	Weak
8	Ma et al. 2012	Questionnaire	Questions whether they had applied statistical methods to clinical practice/researches.	Higher in PBL***.	Weak
		Faculty evaluation	Theoretical examination at the end of the course	NSD	Moderate
			Two years later on same item.	Higher in PBL***.
9	[43]	Faculty evaluation	Total scores comprised of a.written examination, b.practical test on anatomical specimens and c.PBL evaluation.	Higher in PBL**. Additionally, positive correlations were seen in PBL and written examination scores, PBL and practical test scores.	Moderate
		Five-point Likert scale questionnaire	The level of students’ satisfaction or dissatisfaction with the regional anatomy course	Higher in PBL*.	Weak

* Significant difference (p < .05); **Significant difference (p < .01); ***Significant difference (p < 0.001).

PBL: problem-based learning; NSD: no significant difference; CDAS: common disease with atypical symptoms; RD: rare disease.

Table 3. Summary of outcome variables, results, and quality assessment of included studies (whole course intervention).

No.	Study	Evaluation tool	Outcome Variables	Results	Study Quality
1	[26]	Self-study assessment tools	Skala Attitudes Skills	Higher in PBL*.	Weak
			Communication Skills	Higher in PBL*.
			Chinese version of the Critical Thinking Scale	Higher in PBL*.
			Innovation ability	NSD
		10-point system	The overall attitude	The experimental group have statistically significant differences in the experimental classes, satisfaction*, sense of responsibility*, and confidence in future work*.	Weak
			Clinical ability	After 4 weeks of teaching, except for the clinical management ability (NSD), the total scores of the clinical emergency ability of the PBL teaching group were significantly higher*.
			The adaptability, satisfaction, pressure, and improving communication skills of the teaching method	The overall adaptation rate of the experimental group is lower*. From the perspective of stress, satisfaction and the improvement of personal communication skill, the experimental group’s score is higher*.
		Comprehensive examination transcript	Theoretical scores	Higher in PBL*.	Moderate
2	[28]	Self-evaluation	Theoretical knowledge and practical skills, case analysis and classroom performance	Higher in PBL***.	Weak
			Comprehensive ability contained the students’ a. learning, b. cooperation, c. clinical thinking, d. communication skills, e. problem solving abilities.	Higher in PBL for (a), (b), (d), (e)***, higher in PBL for (c)**.
		Doctor–patient communication skills evaluation scale	Initiating communication; b. collecting information; c.giving information d. understanding of the child; e. ending communication	All higher in PBL***.	Moderate
		Questionnaires	Study satisfaction	All higher in PBL***.	Weak
3	[29]	Four-point rating scale postal questionnaires	learning initiative; b. problem solving ability; c. critical thinking; d. clinical work ability; e. independent information acquisition ability; f. teamwork spirit.	All higher in PBL*.	Weak
		Faculty evaluation	Theoretical knowledge test	Higher in PBL*.	Weak
			Operational ability contained nursing simulation and comprehensive ward rounds	Higher in PBL**.
			Medical record writing	Higher in PBL*.
		CTDI-CV	The critical thinking	Higher in PBL for open thinking***, cognitive maturity***, analytical ability***, systematization ability***, and critical thinking***.	Moderate
4	[31]	Evaluation form	Participation, preparation, communication skills, critical discussion, and teamwork.	All higher in strong CT group accepted late-Half PBL tutorials***.	Weak
		CTDI-CV	The critical thinking contained a. truth Seeking; b.open-mindedness; c. analyticity; d.systematicity; e.self-confidence; f.inquisitiveness; g.cognitive maturity	PBL score was higher in (b)*, (c)*, (d)**, (e)*, NSD in other items.	Moderate
5	32	Faculty evaluation	Theoretical knowledge test	Higher in PBL for questions at the theoretical level**, understanding level** and application questions, NSD in questions at the conceptual level.	Moderate
		5-point Likert 5 system self-measurement	a. learning motivation; b. planning and implementation; c. self-monitoring and e. interpersonal communication	Higher in PBL for (a)**, (c)**, (d)**, NSD in (b).	Weak
		Four options self-designed questionnaire	Student satisfaction	92.6% of students were satisfied with the course in the experimental group.	Weak
6	35	Faculty evaluation	Theoretical knowledge test	Higher in PBL*.	Moderate
		5-item statement questionnaire	Comprehensive evaluation for a. increased attention to lectures, b. learning to enhance the enthusiasm, c. increased Language Proficiency d. obtain a larger amount of information, e. better understanding of basic knowledge	All higher after PBL.	Weak
7	[36]	7-item statement questionnaires	Evaluation for a. expanding in knowledge range and depth, b. improvement in autonomous learning ability, c. improvement in problem-analyzing and solving, d. improvement in experimental skills, e. improvement in scientific thinking, f. improvement in language expression and interpersonal, g. communication, h. cultivation in cooperative awareness and team spirits	All higher after PBL .	Weak
8	[37]	10-points faculty evaluation	Evaluation for a.medical record writing, b.clinical case analysis, c.clinical skills assessment, d.written examination scores in every stage and e.behavioral observation	PBL score was higher in (ba)*, (c)*, (e)*, NSD in other items.	Moderate
		Telephone interview	The time investment in teaching for teachers.	In the PBL group, students took an average of 6 h in class and 11 h after school to complete a case, while in the control group, students spent an average of 3 h in class and 3 h after school on the corresponding contents.	Weak
			The time investment in learning for students.	Teachers spent approximately 10 h preparing for one lecture in the PBL group compared with 3 h in the control group.
9	[39]	Faculty evaluation	Examination combined a.multiple-choice, b.short-essay test and c.case-analysis test.	Higher in PBL for (b)*, (c)*, NSD for (a)	Moderate
		Questionnaire	Students’ preference for either hybrid-PBL or LBL teaching	Higher in PBL*.	Weak
			Students’ satisfaction with the the content, framework and subjective effects of hybrid-PBL courses.	It revealed a high overall satisfaction with the course (mean: 4.1 on the fivepoint-Lickert-scale).
10	[41]	Faculty evaluation	Theoretical examination	Higher in PBL*.	Moderate
		Questionnaires	Study satisfaction	Higher in PBL*.	Weak
11	[42]	10-point Likert self-measurement	Evaluation for a. study interest, b.helpfulness in studying dental alveolar surgery, c.improvement in knowledge and clinical skill, d.motivation for cooperating with classmates and e.confidence in clinic practice.	Higher in PBL***.	Weak
		Faculty evaluation	Clinical skill test	ALL higher in PBL**.	Moderate
		Theoretical examination	Multiplechoice examinations	Higher in PBL*.	Moderate
			The same items after 1-year clinical rotation.	Higher in PBL*.
12	[44]	Faculty evaluation	Theoretical and case analysis examinations	Both higher in PBL***.	Moderate
		Five-point rating scale postal questionnaires	Questions focused on the a.identification of the strengths of each teaching method based on the assumptions of each proponent, b.the achievement of specific learning objectives, c.general curricular questions, and d.overall preference for each teaching method	Of the 90 students,satisfaction with their teaching model was greater in the PBL group (92%, 55 of 60) than in their counterparts in the conventional group (67%, 20 of 30).	Weak

* Significant difference (p < .05); **Significant difference (p < .01); ***Significant difference (p < .001).

PBL: problem-based learning; CDAS: common disease with atypical symptoms; RD: rare disease; CTDI-CV: critical thinking disposition inventory-Chinese version.

Bai S, Zhang L, Ye Z, et al. The benefits of using atypical presentations and rare diseases in problem-based learning in undergraduate medical education. BMC Med Educ. 2023;23(1):93. doi: 10.1186/s12909-023-04079-6

 PubMed Web of Science ®Google Scholar

Xu X, Wang Y, Zhang S, et al. Performance of problem-based learning based image teaching in clinical emergency teaching. Front Genet. 2022;13:931640. doi: 10.3389/fgene.2022.931640

 PubMed Web of Science ®Google Scholar

Wang H, Xuan J, Liu L, et al. Problem-based learning and case-based learning in dental education. Ann Transl Med. 2021;9(14):1137–1137. doi: 10.21037/atm-21-165

 PubMed Web of Science ®Google Scholar

Peng W-S, Wang L, Zhang H, et al. Application of virtual scenario simulation combined with problem-based learning for paediatric medical students. J Int Med Res. 2021;49(2):300060520979210. doi: 10.1177/0300060520979210

 PubMed Web of Science ®Google Scholar

Zheng S, Zhang M, Zhao C, et al. The effect of PBL combined with comparative nursing rounds on the teaching of nursing for traumatology. Am J Transl Res. 2021;13(4):3618–3625.

 PubMed Web of Science ®Google Scholar

Li X, Xie F, Li X, et al. Development, application, and evaluation of a problem-based learning method in clinical laboratory education. Clin Chim Acta. 2020;510:681–684. doi: 10.1016/j.cca.2020.08.037

 PubMed Web of Science ®Google Scholar

Pu D, Ni J, Song D, et al. Influence of critical thinking disposition on the learning efficiency of problem-based learning in undergraduate medical students. BMC Med Educ. 2019;19:1.

 PubMed Web of Science ®Google Scholar

Ding Y, Zhang P. Practice and effectiveness of web-based problem-based learning approach in a large class-size system: a comparative study. Nurse Educ Pract. 2018;31:161–164. doi: 10.1016/j.nepr.2018.06.009

 PubMed Web of Science ®Google Scholar

Cong L, Yan Q, Sun C, et al. Effect of problem and scripting-based learning on spine surgical trainees’ learning outcomes. Eur Spine J. 2017;26(12):3068–3074. doi: 10.1007/s00586-017-5135-2

 PubMed Web of Science ®Google Scholar

Bai X, Zhang X, Wang X, et al. Follow-up assessment of problem-based learning in dental alveolar surgery education: a pilot trial. Int Dent J. 2017;67(3):180–185. doi: 10.1111/idj.12275

 PubMed Web of Science ®Google Scholar

Du Y. 2017. The application of PBL teaching method in the teaching of traditional chinese medicine nursing. Proceedings of the 7th International Conference on Education, Management, Information and Mechanical Engineering (EMIM 2017). Shenyang, China: Atlantis Press. doi: 10.2991/emim-17.2017.296

 Google Scholar

Li H, Wang C, Zhang C, et al. Application of PBL method in the experimental teaching of clinical pharmacology. Atlantis Press; 2016; p. 57–60. doi: 10.2991/sshme-16.2016.11

 Google Scholar

Rui Z, Rong-Zheng Y, Hong-Yu Q, et al. Preliminary investigation into application of problem-based learning in the practical teaching of diagnostics. Adv Med Educ Pract. 2015;6:223–229. doi: 10.2147/AMEP.S78893

 PubMedGoogle Scholar

Yu D, Zhang Y, Xu Y, et al. Improvement in critical thinking dispositions of undergraduate nursing students through problem-based learning: a crossover-experimental study. J Nurs Educ. 2013;52(10):574–581. doi: 10.3928/01484834-20130924-02

 PubMed Web of Science ®Google Scholar

Lian J, He F. Improved performance of students instructed in a hybrid PBL format. Biochem Mol Biol Educ. 2013;41(1):5–10. doi: 10.1002/bmb.20666

 PubMed Web of Science ®Google Scholar

Li J, Li QL, Li J, et al. Comparison of three problem-based learning conditions (real patients, digital and paper) with lecture-based learning in a dermatology course: a prospective randomized study from China. Med Teach. 2013;35(2):e963–970. doi: 10.3109/0142159X.2012.719651

 PubMed Web of Science ®Google Scholar

Tian J-H, Yang K-H, Liu A-P. Problem-based learning in evidence-based medicine courses at Lanzhou University. Med Teach. 2012;34(4):341–341. doi: 10.3109/0142159X.2011.531169

 PubMed Web of Science ®Google Scholar

Zhang Y, Chen G, Fang X, et al. Problem-based learning in oral and maxillofacial surgery education: the shanghai hybrid. J Oral Maxillofac Surg. 2012;70(1):e7–e11. doi: 10.1016/j.joms.2011.03.038

 PubMed Web of Science ®Google Scholar

Wang J, Zhang W, Qin L, et al. Problem-based learning in regional anatomy education at Peking University. Anat Sci Educ. 2010;3(3):121–126. doi: 10.1002/ase.151

 PubMed Web of Science ®Google Scholar

Kong J, Li X, Wang Y, et al. Effect of digital problem-based learning cases on student learning outcomes in ophthalmology courses. Arch Ophthalmol. 2009;127(9):1211–1214. doi: 10.1001/archophthalmol.2009.110

 PubMedGoogle Scholar

Data availability statement

All data supporting the reported results are available in the original studies included in the systematic review and were showed in figures and tables included in the present manuscript.