Visualization analysis of CBL application in Chinese and international medical education based on big data mining | BMC Medical Education

Publication trend

The application of CBL in medical education has mirrored the progression observed in other natural science domains, undergoing stages of initial development, steady growth, and rapid expansion. During the initial stage from 1995 to 2006, CBL pedagogy was in its nascent form, with limited publications. From 2007 to 2014, a phase of steady growth was observed, with Chinese publications showing more significant growth than English counterparts. This period saw the CBL teaching model evolve rapidly from single applications to mixed implementations encompassing multiple teaching models. Initially employed primarily in fundamental disciplines such as tissue and embryology, CBL gradually extended its reach into more clinical fields [8]. English literature on CBL encompasses diverse publication types and introduces innovative teaching, methods including the integration of CBL mode with games [9].

Since 2015, CBL teaching entered a stage of rapid development. Chinese literature, with a total of 79 articles, is projected to peak in 2021, emphasizing the combination of CBL with other teaching modes such as sandwich method [10], problem-based teaching method [11] and virtual simulation teaching [12]. English literature, on the other hand, with a total of 86 articles, reached its zenith in 2022. It has often kept pace with contemporary trends in science and technology by exploring various themes and incorporating novel elements like WeChat [13], 3D printing [14] and virtual environment teaching [15].

Author co-occurrence analysis

The author serves as the fundamental driving force behind research, and identifying prolific authors and core groups provides an overview of the research field. Compared to natural science, the number of published papers in this field is significantly lower. This phenomenon can be attributed to the inherent characteristics of medical education itself; namely, its exploration phase tends to be relatively lengthy with most endeavors spanning at least one semester or six months. When an effective teaching method is discovered, it is often continued for some time rather than immediately introducing another approach. This is in contrast to natural science, where a single author has published 93 papers within just 11 years [16]. In our study, the highest number of publications by a single author in both Chinese and English is merely 9, and the field exhibits a publication centrality value of 0, indicating no burst authors emerging within a short period. For example, Fischer Martin RL, whose publications rank second in quantity, has been engaged in teaching research from 2008 to 2020. In 2008, he conducted team-based and case-oriented teaching research [17], while in 2020 he attempted to introduce digital teaching methods [18]. However, only six articles were published over this twelve-year span. This suggests that the research in medical education is more focused on long-term, sustained efforts rather than rapid, high-volume output.

Research institution analysis

The institutions with the highest number of Chinese and English literature publications primarily consist of universities or university-affiliated institutions. The University of Toronto leads in terms of English papers, with 15 papers published consistently from 2011 to 2022, focusing on the application of CBL in community health service teaching. Their research also encompasses physiotherapist and resident training, dermatology instruction, end-of-life care assistance, immunization courses, and coronary heart disease studies. Following closely are the University of California, San Francisco; the University of New Mexico; and Emory University, each having published seven papers. Notably, over the past two years, the University of California, San Francisco has emphasized keeping pace with contemporary advancements by exploring medical school curriculum reform and enhancing integration between basic science and clinical science disciplines as well as radiotherapy expertise. The virtual conference conducted through Zoom’s artificial intelligence-powered platform effectively combines CBL teaching outcomes.

The Beihua University Affiliated Hospital ranked first in the number of Chinese publications (11 papers) published annually from 2011 to 2018, primarily focusing on the application of CBL in otorhinolaryngology, orthopedics, imaging, and other disciplines as well as resident training. Other publications also predominantly explore the implementation of CBL across various fields of education. Overall, it is evident that English literature research in this area is more advanced than its Chinese counterparts, highlighting the need for interdisciplinary integration and diverse teaching methodologies to foster continuous development and innovation.

Keyword analysis

Keyword co-occurrence analysis

The co-occurrence of keywords in both Chinese and English literature reveals distinct research foci. English literature tends to concentrate on students’ academic performance and course attitudes, reflecting a student-centered approach. In contrast, Chinese literature emphasizes overall design and teaching reform, indicating a system-oriented approach to educational improvement. This difference may stem from the varying educational contexts and research priorities in these regions.

Keyword bursts analysis

In the field of English literature, the first category of keywords is centered on student learning. Notably, Singh K and colleagues have effectively implemented Team-based Learning (TBL), CBL, and flipped classroom approaches in anatomy education. Their study underscores the significant impact of integrating active and engaging learning strategies on enhancing the acquisition of anatomical knowledge. Students are particularly active in preparing muscle presentations, drawing on their creativity, curiosity, and intellectual capabilities [19].

The second category of keywords related to teaching courses. Students have actively engaged in collaborative knowledge construction through online interprofessional CBL implementation; however, they expressed a preference for offline collaborative practice, which they believe better fosters team bonding—a key component of effective collaboration [20].

The third category of keywords focuses on teaching methods. As recently as 2021, Germany was actively developing a novel radiology curriculum for medical research aiming for national consensus on incorporating multiple teaching modes into their educational framework, including CBL and the flipped classroom [21]. Although most literature suggests that CBL combined with other teaching methods improves teaching quality and student motivation, Maia D et al., through meta-analysis, have noted a very low level of certainty regarding the evidence for CBL in conjunction with other pedagogical approaches, indicating a need for further research to draw more robust conclusions [22].

Over the past two years, there has been a significant evolution in the prominent terms “distance” and “social media”, closely linked to the global outbreak of the novel coronavirus. Notably, these terms are often used interchangeably. As highlighted by Grady Z.J. et al. on March 17, 2020, due to the COVID-19 pandemic, medical students were advised by the Association of American Medical Colleges to disengage from clinical settings. Consequently, to ensure continuous education, a virtual elective course in surgery was introduced [23]. This marked the beginning of remote learning practices. Additionally, social media platforms are increasingly being utilized for professional purposes such as scientific updates, networking opportunities, and CBL [24]. It is worth noting that different countries have adopted social media applications based on national contexts, for example, Instagram [25] is used by Wake Forest University in the United States, while WeChat [26] is widely used in China and WhatsApp [27] is popular in many other regions.

The fourth category relates to geographical locations. According to Furlan AD’s report, a lack of adequate knowledge and training among healthcare providers hinders the effective management of chronic pain. To address this issue, ECHO (Community Healthcare Outcomes Expansion) utilizes CBL and video conferencing to connect specialists with providers in underserved areas, thereby enhancing healthcare providers’ self-efficacy and knowledge [28].

In Chinese literature, the first category of keywords is closely linked to national policies and the guidance provided by MOE. Medical education also adheres to national policies. In 2020, the MOE released the Outline of Curriculum Ideology and Politics Construction in Colleges and Universities. 2009 marked a significant push for quality education, emphasizing students’ innovative spirit and practical abilities.

The second category of keywords pertains closely to the evaluation and methods employed in teaching. The emergence of flipped classroom and mind mapping signifying that teaching is inseparable from the assessment of teaching outcomes and reforms in instructional approaches.

The third category pertains to teaching courses and their application fields, encompassing several prominent keywords. The validation and implementation of a teaching method necessitate its application across diverse disciplines.

In summary, the emergence of keywords in Chinese and English literature shows both similarities and differences. Moreover, significant disciplinary, pedagogical, and national factors influence the occurrence of key words within a specific timeframe. These factors include global and domestic policies such as distance learning, social media applications, the ECHO project, and the rise of ideological and political courses in China. However, it is important to note that English literature tends to provide more extensive accounts on students’ learning experiences compared to Chinese literature which primarily focuses on summarizing teaching effectiveness.

Keywords cluster analysis

In the English literature, studies on care have explored various aspects of medical education and healthcare delivery. Hong et al. conducted a comparative study on the impact of unfolding nursing cases versus usual nursing cases on teaching effectiveness. Their findings revealed that unfolding nursing cases significantly enhance the critical thinking ability of nursing undergraduates compared to usual nursing cases [29]. Seymour R et al. investigated healthcare for individuals with disabilities, highlighting that CBL offers significant opportunities to address disability discrimination and better equip students to handle negative attitudes contributing to health disparities among this population [30]. Electronic consultation (eConsult), which involves asynchronous communication between primary care providers (PCPs) and specialists, is increasingly used in healthcare systems to streamline care delivery and enhance patient access. Deeds et al., through 35 semi-structured interviews and six focus groups with various primary care providers from seven academic medical centers (AMCs) affiliated with the Association American Medical Colleges (AAMC), found that eConsult improved comprehensiveness in primary care while also addressing knowledge gaps among PCPs through CBL [31]. Furthermore, the reach of this type of healthcare into rural areas is expanded through the implementation of distributed community engaged learning (DCEL), a unique medical education model developed by the Northern Ontario School of Medicine. The DCEL approach encompasses various strategies such as CBL, community-based medical education, electronic distance education, rural-based medical education (including the preceptor model), allowing students to explore cases from physicians’ perspectives within classroom and clinical settings in Northern Ontario [32].

In research on community practices and special projects and populations, CBL is widely used in community of practice and workplace learning, covering training content related to chronic pain, problem-based learning, and interdisciplinary approaches [33]. For example, Tosi LL et al. successfully implemented CBL in telehealth assistance for rare bone diseases on a global scale [34]. Additionally, CBL is extensively applied in the Extension for Community Healthcare Outcomes (ECHO) project [35, 36], which incorporates educational technology, coaching methodologies, curriculum development strategies, and career advancement initiatives that are variably employed or represented within ECHO and similar programs [37]. Pre-service training for teachers presents challenges that can be addressed by CBL. Heemsoth T et al. conducted pre-service teacher training using video- and text-based teaching cases focused on “teaching games for understanding,” yielding promising results for physical education teachers [2]. Kramer C et al. advocate that CBL is a promising approach to integrate theory with practice within teacher education programs [38]. These applications of CBL highlight its versatility in enhancing educational and professional development across various settings and populations.

The clustering of research on teaching methods introduces the joint application and comparative situations of CBL with other teaching methods. Blended learning merges online and offline instruction, integrating e-learning with traditional methods [39,40,41]. Though CBL can be incorporated into preclinical curricula, it cannot fully replace didactic learning [42]. To change clinical behaviors, CBL is often combined with evidence-based practice [43, 44]. CBL has been used in clinical teaching [45], clinicopathology courses [46], and general medical education initiatives [43, 47], but requires active participation from teachers and medical students. Problem-based learning, CBL, and narrative approaches can be applied in various disciplines and training programs [48]. Case-based teaching and curricula focus on instruction delivery, while CBL emphasizes student engagement. Lecture-based learning and blended learning with case studies are often integrated with other methods. During COVID-19, Zottmann JM et al. successfully digitized an interactive, case-based teaching model for Clinical Case Discussion, which was well-received and showed potential for enhancing clinical reasoning abilities [18]. Jiang Z et al. implemented LBL, CBL, PBL, RBL, and TBL in online dental education during the pandemic, finding higher student satisfaction with LBL and CBL. Jiang Z et al. implemented LBL, CBL, PBL, research-based learning (RBL) and team-based learning (TBL) in online dental education during the pandemic, finding that students were more satisfied with LBL and CBL [49]. Educational games may improve health professionals’ performance, but a 2013 review by Akl EA et al. found inconclusive evidence regarding their effectiveness [50]. Additionally, game strategies have been linked to knowledge retention, attitude improvement, and job satisfaction among healthcare workers.

In research on competence development of participants, the literature on CBL encompasses a range of topics. These include students’ attitudes towards cross-professional learning [3], case cooperative learning [51], and their experiences and views on using 3D printing for learning coronary heart disease [52]. Additionally, there is research students’ career attitudes [53], and the positive correlation between exam scores in lecture-based and case-based integrated learning and career attitudes. Additionally, implicit attitudes transmitted through generations in the medical education system have also been identified [54], referring to unwritten knowledge passed down from teaching physicians to future generations. Studies explore radiology residents’ attitudes toward patient-centered nursing principles [55], and medical students’ views on malpractice. Satisfaction with CBL programs has been assessed [56], as have attitudes toward CBL in the physiology curriculum [46] and primary care providers’ (PCPs) attitudes towards obesity. Intervention training has been shown to improve negative attitudes toward obesity and boost confidence in helping patients control their weight [57].

Clinical competence is crucial for healthcare professionals. Gupta et al. found that integrating virtual patients with CBL offers a more engaging approach for school doctors’ clinical skills than traditional paper cases, enhancing clinical reasoning and experience transfer [4]. Amid the COVID-19 pandemic, CBL has become more popular among medical students [58], a notable increase in the evaluation of clinical performance in fields like radiology education [59].

Decision-making skills are vital in clinical practice, and can be enhanced through active learning methods incorporating clinical case studies [60]. The combination of the flipped classroom and CBL also improves decision-making skills [61]. Teaching approaches involving real or specialized patient exposure, technology-enhanced CBL, and graphical clinical cases representations provide learners opportunities to enhance their clinical reasoning. These approaches also allow them to explore interactions between diseases and social determinants, as well as conflicting treatment approaches [62].

In the Chinese literature, teaching applications aligned with national policy guidance constitute applied research that follows this guidance. The main goal is to improve the professional quality education for medical students, enhance their training in medical ethics and scientific research integrity, fully leverage the ideological and political role of this course, and cultivate a spirit among medical students that emphasizes saving lives and healing injuries [63].

The application of CBL in educational reform, methods, and evaluation highlights its utility for enhancing teaching practices. Diverse teaching methods boost students’ interest in pathogen biology and immunology, deepen their understanding, and foster a sense of responsibility and mission for further exploration and discovery, while also building a strong foundation for clinical thinking ability [64]. As a follow-up approach, the combination of PBL for practical courses and CBL for theoretical courses not only develops medical students’ clinical thinking ability but also increases teachers’ enthusiasm for educational reforms [65]. Integrating a WeChat platform flipped classroom with PBL and CBL teaching methods in thoracic surgery clinical practice has shown positive outcomes and is recommended for undergraduate students in clinical medicine [66]. Cross-training through application cases, special report meetings, and scientific research practices outperforms traditional training, aiding in the development of multidisciplinary health management talents to meet societal healthcare needs [67].

In terms of CBL application across disciplines, combining the case teaching method with evidence-based medicine instruction improves outcomes. Understanding evidence-based medicine concepts and skills is crucial for clinical medical students’ use of research evidence, independent learning, and clinical practice [68]. Biochemistry, a fundamental discipline, highlights teachers’ role in effective instruction, as seen in keywords published in 2020 [69]. Narrative, contrasting with evidence-based medicine, has seen a keyword mutation. Online moral education case integration based on medical narrative significantly enhances nursing students’ critical thinking and empathy [70].

In terms of keyword clustering methods, English and Chinese literature share similarities but also exhibit differences in their approaches. Both types of literature have been widely utilized across various disciplines. They encompass national policy applications and explorations into teaching method changes, effectiveness, and student ability assessment. However, a key distinction lies in the broader application scope of English literature, including public projects such as the ECHO project and conference training.

Although this study is comprehensive, it has several limitations. First, the literature search, despite using multiple databases, may have missed some relevant studies due to regional terminology variations or exclusion of grey literature, such as unpublished dissertations or conference proceedings, which may introduce selection bias. Second, the data mining techniques, including CiteSpace software, rely on accurate and consistent data input. Errors or inconsistencies in the original data, such as misspelled keywords or incorrect author affiliations, could skew the analysis results. Moreover, the clustering and burst analysis methods may not fully capture the field’s complexity, possibly overlooking emerging low-frequency topics or inaccurately reflecting certain keywords’ long-term significance. Third, the study focuses on quantitative analysis, which may not fully capture qualitative aspects like theoretical depth or empirical study quality. A more in-depth qualitative analysis could provide additional insights, but this was beyond the scope of this review. Lastly, the review is based on data collected up to October 27, 2023. Given the rapid evolution of medical education and CBL, new studies published after this date may present different trends or findings. Thus, the conclusions should be considered in light of these limitations and updated with new data.