“Internet+” Case-Based Learning Improves Perceived Learning Gains and Teaching Satisfaction in an Integrated Medical Curriculum: A Comparative Study

Ethics Declarations

This study was approved by the Renmin Hospital of Wuhan University Clinical Research Ethics Committee (approval number: WDRY2023-K001). This study adhered to the Declaration of Helsinki. All methods were performed in accordance with relevant guidelines and regulations. All participants provided written informed consent before proceeding with any research activities.

Study Design and Sample Size Calculation

This study is a within-subject comparative survey. The total number of students who met the inclusion criteria was approximately 210. All eligible students were invited to participate, and a total of 180 valid questionnaires were finally obtained, covering 85.7% of the target population, demonstrating good representativeness. A post-hoc analysis based on the primary outcome measure yielded an effect size of Cohen’s d ≈ 0.304. Assuming α = 0.05 and power (1−β) = 0.80, the minimum required sample size was approximately 90. The actual study included 180 paired valid responses, far exceeding the minimum requirement, and the post-hoc power analysis showed 1−β > 0.95, indicating that the sample size was adequate.

Two-Stage CPPT Teaching Modality

The CPPT course was delivered in two sequential stages (Figure 1). In the first stage (CPPT1), the “Internet+” CBL modality was implemented. This modality incorporated the following digital components: (a) pre-class online guiding questions and case previews – before each discussion session, students received a set of guiding questions and electronic case materials via an online platform, which they were expected to review and research independently; (b) electronic pathology slide library – a comprehensive digital library of pathology slides was established, accessible through the university’s learning management system, enabling students to view and study slides at any time using personal electronic devices; and (c) post-class online homework – after each session, students completed a brief online quiz or exercise designed to consolidate their understanding of the key concepts covered in the case discussion. In the second stage (CPPT2), the traditional CBL modality was employed. None of the above online resources were provided. Teaching relied exclusively on face-to-face lectures, paper-based case handouts, and in-class discussions without any digital pre-class or post-class components.

Inclusion and Exclusion Criteria

Fourth-year clinical medical undergraduates from the First Clinical School of Wuhan University were enrolled in this study from July 2022- August 2024. Inclusion criteria were as follows: (a) had completed both phases of the CPPT course in their entirety; (b) agreed to participate voluntarily and provided written informed consent. The main exclusion criteria included: (a) incomplete completion of both phases of the CPPT course; (b) incomplete questionnaire responses or logically inconsistent responses (e.g., identical ratings across all items); or (c) inability to provide informed consent.

Survey Methods

Combined with an evaluation of teaching satisfaction and perceived learning gains, we designed and distributed the “Learning Experience” questionnaire. Questionnaires were distributed and collected using Wenjuanxing (a platform that provides the function of editing and sending questionnaires). Exclusionary questions were set in the questionnaire to ensure that all subjects were medical-related students who had experienced both “Internet +” CBL and traditional CBL teaching modes.

General Information Survey

This includes the age, gender, grade, and major of students.

“Learning Experience” Questionnaire

The questionnaire was adapted to the actual situation based on the students’ evaluations of educational quality (SEEQ), ¹² which is used to evaluate students’ learning experience in different teaching modes. It consists of two types of questions: general information, and comparative scoring, which mainly reflect teaching satisfaction and perceived learning gains. Comparative scoring questions had five choices, with one point for “strongly disagree,” two points for “disagree,” three points for “fair,” four points for “agree” and five points for “strongly agree”. ¹³ We conducted a pilot test on 10 students from the same major who did not participate in the formal study, and made minor adjustments to the questionnaire based on the results. Additionally, five experts with backgrounds in educational research methodology (including one course teaching expert, one medical education researcher, and three instructors) were invited to independently evaluate the content validity of the revised questionnaire. The results showed that the item-level content validity index (I-CVI) ranged from 0.80 to 1.00, and the scale-level average content validity index (S-CVI/Ave) was 0.96, indicating good content validity of the adapted questionnaire. In the formal study, Cronbach’s alpha coefficient of the questionnaire was 0.924, demonstrating excellent internal consistency. This study employed a convenience sampling method, and all students voluntarily participated in the experiment. It should be noted that voluntary participation does not equate to random sampling; therefore, the generalizability of the findings may have certain limitations. In terms of questionnaire content design, all questions were asked twice to obtain student scorings of the two different educational modes.

Statistical Analysis

For continuous variables, data were reported as mean ± SD or P₅₀ [P₂₅, P₇₅] and analyzed by paired t test or Wilcoxon matched-pairs signed rank test. For the count variables, data were presented as percentage or rate. All data were analyzed using the SPSS software program (version 26.0.0, IBM Corp, Armonk, NY), and a two-tailed P < 0.05 was considered significant.

General Information

A total of 190 questionnaires were collected between July 2022 and August 2024, of which 180 were valid, yielding an effective response rate of 94.7%. The respondents were fourth-year undergraduate medical students from the First Clinical School of Wuhan University, including 62 (34.4%) from the five-year clinical medicine program, 72 (40.0%) from the “5+3” integrated program, and 46 (25.6%) from the eight-year program. The age of participants was 20.29 ± 0.81 years, with 56 male (31.1%) and 124 female (68.9%) students. All respondents had completed both phases of the CPPT course and experienced both “Internet+” CBL and traditional CBL modalities.

Comparative Analysis of Teaching Satisfaction

Comparative Analysis of Perceived Learning Gains

Self-Learning and Collaborative Skills

Students rated the “Internet+” CBL mode significantly higher in enhancing their ability to collect and analyze information through online preview (Item 17) (P=0.036). Online homework was also perceived as more effective in strengthening communication and teamwork skills in the “Internet+” group (Item 20) (P=0.024). No significant difference was observed in the perceived contribution of advance case preview to self-study ability (Item 16) (P=0.217).

Collectively, regarding teaching satisfaction, “Internet +” CBL is generally better than traditional CBL, but it will increase the learning burden of students. In terms of perceived learning gains, “Internet +” CBL can improve students’ abilities in multiple aspects (Figure 2A-C). Details of the questionnaire are shown in Table 1.OPEN IN VIEWER

Figure 2.

Results of the questionnaire research. (A) Comparison of teaching satisfaction in the two groups. (B) Results of perceived learning gains. (C) Average scores of the two groups in terms of teaching satisfaction and perceived learning gains. ^*P < 0.05; ^**P < 0.01; ^***P < 0.001; ^****P < 0.0001; ns, no statistical significance.

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Table 1.

Evaluation of Teaching Satisfaction and Perceived Learning Gains

Items	“Internet +” CBL		Traditional CBL		P value	r rb
	P50	[P25, P75]	P50	[P25, P75]
Satisfaction with teaching
1. Finishing the preview exercises in advance will increase my workload.	3.00	[2.00, 4.00]	3.00	[2.00, 3.00]	<0.001c	0.850
2. Collect questions before class to make the teacher’s teaching more targeted.	4.00	[3.00, 5.00]	4.00	[3.00, 4.00]	0.011a	0.620
3. I can timely understand the learning requirements and key contents before class discussion.	4.00	[4.00, 5.00]	4.00	[3.00, 4.00]	0.004b	0.620
4. I often ask questions in the pre-class question collection.	3.00	[2.00, 3.00]	3.00	[2.00, 3.00]	0.042a	0.571
5. Preview cases in advance can make my study in the discussion class more targeted.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	<0.001c	0.757
6. The learning resources provided by the course (questionnaire, case PPT, etc.) play a guiding role in my study.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	0.018a	0.608
7. The teaching resources provided by the course are more conducive to my study plan in advance.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	0.068	0.591
8. Online homework after class helps to consolidate my understanding of knowledge.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	<0.001c	0.814
9. The slides in the electronic pathology slide library are consistent with the syllabus as a whole.	4.00	[3.00,4.25]	4.00	[3.00,4.00]	0.004b	0.629
10. The homework increases my workload.	3.00	[2.00, 4.00]	3.00	[2.00, 3.00]	0.004b	0.846
11. My questions can get timely feedback in online group (such as WeChat).	4.00	[4.00, 4.00]	4.00	[3.00, 4.00]	0.098	0.611
12. I think the number of seminar cases matches the class hours.	4.00	[3.00, 4.00]	4.00	[3.00, 4.00]	<0.001c	0.938
Perceived learning gains						​
13. My knowledge of disease diagnosis and differential diagnosis has improved.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	0.048a	0.539
14. I have a good command of theoretical knowledge.	4.00	[4.00, 5.00]	4.00	[3.00, 4.00]	0.305	0.250
15. My case analysis ability has been greatly improved.	4.00	[4.00, 5.00]	4.00	[4.00, 4.00]	0.019a	0.667
16. Previewing cases in advance is conducive to improving my self-study ability.	4.00	[4.00, 4.00]	4.00	[4.00, 4.00]	0.217	0.394
17. Online preview in advance is helpful to improve my ability of information collection and analysis.	4.00	[4.00, 5.00]	4.00	[4.00, 4.00]	0.036a	0.604
18. My clinical thinking has been improved through discussion courses.	4.00	[4.00, 5.00]	4.00	[4.00, 5.00]	0.077	0.500
19. The course improved my ability to interpret pathological images.	4.00	[3.00, 4.00]	4.00	[3.00, 4.00]	0.011a	0.714
20. The online homework after class strengthened my communication skills and teamwork ability.	4.00	[3.00, 4.00]	4.00	[3.00, 4.00]	0.024a	0.872

Note. P^a<0.05; P^b<0.01; P^c<0.001; P₂₅ = 25th percentile; P₅₀ = median; P₇₅ = 75th percentile; r_rb = Rank-Biserial correlation coefficient.

Major Findings

This study compared “Internet+” CBL and traditional CBL within an integrated CPPT curriculum, revealing that the technology-enhanced approach significantly outperformed its conventional counterpart in multiple dimensions of teaching satisfaction and self-reported learning outcomes, albeit with an increased perceived workload. These findings align with the growing body of evidence supporting the integration of digital tools into case-based medical education. However, the observed trade-off between enhanced learning experiences and increased student workload warrants careful consideration in curriculum design.

“Internet+” CBL Enhanced Teaching Satisfaction

The superior teaching satisfaction ratings for “Internet+” CBL can be attributed primarily to its structured pre-class components, including online questionnaires, case previews, and targeted exercises. These elements address a fundamental limitation of traditional CBL: the lack of guided preparation. From a cognitive load theory perspective, ¹⁴ well-designed pre-class activities reduce extraneous cognitive load by orienting students to key concepts and learning objectives before they engage in complex case discussions. This allows working memory resources to be allocated more efficiently to authentic problem-solving during class, rather than being overwhelmed by simultaneous exposure to new content and clinical reasoning demands. ¹⁵

Our finding that pre-class resources enhanced the targeting of teaching (Item 2) and helped students understand learning requirements (Item 3) supports this interpretation. The significantly higher rating for the guiding role of learning resources in “Internet+” CBL (Item 6) further suggests that structured digital materials serve as cognitive scaffolds, helping students navigate the complexity of integrated medical content. This is particularly valuable in courses like CPPT, which synthesize multiple disciplines and require students to integrate basic science knowledge with clinical application.

“Internet+” CBL Improved Self-Reported Learning Outcomes

The “Internet+” CBL modality demonstrated significant advantages over the traditional CBL modality in developing disease diagnosis and differential diagnosis knowledge (Item 13), case analysis ability (Item 15), information collection and analysis skills (Item 17), and pathological recognition (Item 19). These findings resonate with constructivist learning theory, which posits that meaningful learning occurs when learners actively construct knowledge through interaction with authentic problems and resources. The online preview and pre-class questionnaires in “Internet+” CBL transform students from passive recipients of information into active investigators who must gather, evaluate, and synthesize information before entering the classroom.

This preparatory phase likely activates prior knowledge and generates curiosity, creating a “readiness to learn” that enhances the effectiveness of subsequent case discussions. ¹⁶ The step-by-step guidance provided by sequenced online resources may also promote the development of metacognitive skills, as students learn to monitor their own understanding and identify knowledge gaps before class. ¹⁷ The significant improvement in pathological recognition skills specifically may reflect the advantages of the electronic pathology slide library, which offers high-quality images, annotation capabilities, and self-assessment opportunities that are difficult to achieve with traditional printed atlases.

“Internet+” CBL Cultivated Teamwork Skills

The finding that online homework strengthened communication and teamwork skills (Item 20) more effectively in “Internet+” CBL deserves particular attention. This suggests that technology-enhanced CBL not only facilitates individual learning but also creates new opportunities for collaborative knowledge construction. Online discussion forums and group assignments require students to articulate their thinking, respond to peers’ perspectives, and negotiate shared understanding—processes that are central to the development of collaborative competence. ¹⁸ In contrast, traditional CBL often limits collaboration to face-to-face discussions, which may be constrained by time and dominated by more vocal participants. The flexibility of online platforms may also enable more equitable participation, allowing students with different learning styles and communication preferences to contribute meaningfully.

“Internet+” CBL Increased the Learning Workload

Despite its advantages, “Internet+” CBL was associated with significantly higher perceived workload (Items 1 and 10). This finding highlights a critical tension in technology-enhanced education: the same features that enrich learning—additional resources, preparatory tasks, and follow-up exercises—can also increase workload and potentially contribute to student burnout. Importantly, however, students in our study generally considered the workload acceptable, suggesting that the perceived benefits may outweigh the costs. Nonetheless, the higher workload might also reflect factors beyond sheer workload, such as poor calibration of pre-class tasks (e.g., tasks that were too time-consuming or misaligned with students’ available time), suboptimal usability of the online questionnaire platform, or insufficient guidance on how to effectively navigate the pre-class resources. The higher ratings for the guiding role of resources and the perceived relevance of online homework suggest that when using the “Internet+” CBL modality, students may have experienced these tasks as meaningful and instrumental to their learning goals, thereby mitigating the negative impact of increased workload.

Moreover, whether comparable positive effects could be achieved by providing online resources without mandating pre- and post-questionnaires remains unknown. It is possible that optional resources would reduce perceived workload, but may also lead to lower engagement and diminished learning gains for less self-motivated students. Future studies should compare mandatory versus optional designs to determine the optimal balance between structure and flexibility.

Collectively, these findings underscore the importance of thoughtful curriculum design that balances enrichment with feasibility. Strategies to optimize this balance might include: (1) carefully calibrating the number and complexity of pre-class tasks to avoid overload; (2) clearly communicating the purpose and value of each online component; (3) providing flexible deadlines and allowing student choice in some activities; and (4) integrating pre-class preparation with in-class activities to create coherent learning experiences rather than disjointed tasks. ¹⁹

Persistent Challenges: Pre-class Questioning and Teacher-Student Interaction

Both CBL modalities faced challenges in stimulating pre-class questions (Item 4) and facilitating timely teacher-student interaction (Item 11). The low enthusiasm for pre-class questioning may reflect several factors: students’ limited prior knowledge of new topics, lack of confidence in formulating questions, or perception that questions will not receive timely responses. The significantly lower scores for traditional CBL in this domain suggest that digital platforms alone are insufficient to cultivate a questioning culture; deliberate pedagogical strategies are needed.

The persistent challenge of teacher-student interaction in both modes highlights a limitation of current “Internet+” implementations. While technology enables asynchronous communication, it may not automatically foster the kind of responsive, dialogic interaction that characterizes effective teaching.^20,21 Students’ suggestions—dedicated Q&A sessions, more timely online responses, and increased clinical clerkship opportunities—point toward hybrid solutions that combine the flexibility of online platforms with the immediacy and richness of face-to-face interaction.

Confounding Factors and Study Limitations

Several confounding factors of this study should be acknowledged. First, the two teaching modalities were delivered sequentially, with all students first receiving the “Internet+” CBL format followed by the traditional CBL format. This fixed teaching sequence may introduce an order effect, as students’ evaluations of the second modality could be influenced by their prior exposure to the first. Additionally, maturation effect cannot be excluded, as students may have developed enhanced knowledge or skills over time that systematically affected their ratings. The novelty effect is also possible; students might have rated the “Internet+” CBL modality more favorably simply because it was a new, technology-driven approach, rather than due to its inherent pedagogical superiority. Furthermore, teacher differences or variations in implementation across the two phases may have contributed to the observed differences, as different instructors might have emphasized different aspects or interacted with students differently, even though the syllabus and case materials were standardized. The difficulty of clinical curriculum may also have varied across the two phases of the CPPT course, potentially influencing perceived learning gains and satisfaction independently of the teaching modality. Finally, since the questionnaire was administered after the completion of both phases and data were collected over an extended period, recall bias is possible. Students’ retrospective comparisons may be subject to inaccuracies or influenced by the recency of the second phase.

Furthermore, this study has several additional limitations as follows. Firstly, the questionnaire was adapted from the SEEQ to suit the actual situation and may not address the individual questions and requirements of some students. Secondly, although internal consistency of this questionnaire was high (Cronbach’s α > 0.9), test-retest reliability was not evaluated because the survey was administered only once. Thirdly, the questionnaire did not address emotional aspects, which may also have an impact on students’ experiences. Fourthly, as this was a small sample, single-center study, some of our data are speculative rather than confirmatory. Moreover, the sample was predominantly female (68.9%), reflecting the actual gender distribution in our medical program but potentially limiting the generalizability of findings across genders. Due to the small number of male participants, subgroup analysis by gender was not feasible. Future studies with more balanced gender samples are needed to confirm whether the observed advantages of “Internet+” CBL apply equally to both genders. Finally, this study assessed learning outcomes solely through students’ self-reported perceptions rather than objective measures such as examination scores or clinical performance evaluations. Although perceived learning gains provide valuable insight into learners’ confidence and subjective growth, they do not directly equate to actual knowledge acquisition or clinical competence. The two course phases (CPPT1 and CPPT2) covered different clinical topics, precluding direct comparison of objective academic performance. Future studies should adopt a randomized controlled design within the same course content and include objective tests or standardized clinical assessments to validate these findings.