Effectiveness of flipped classrooms in Chinese students of clinical medicine major undergoing clinical practice: a meta-analysis

Abstract

Introduction

Clinical practice is a cornerstone of undergraduate training in Chinese medical education, ensuring the development of essential skills for future professionals. While flipped classrooms have gained popularity for their potential to enhance learning outcomes, the effectiveness of this approach in clinical settings remains underexplored. This study aims to address this research gap by consolidating evidence on the impact of flipped classrooms through a comprehensive meta-analysis.

Methods

Two researchers independently screened all the retrieved articles and did data extraction. The Cochrane Risk of Bias tool for randomized trials was used for methodological quality assessment. Weighted mean differences (WMD) and 95% confidence interval (CI) were used to compare the differences in theoretical and skill scores between the flipped classrooms and traditional lecture groups. The Cochran Q test and the I2 statistic were used for heterogeneity analysis. The funnel plots were used to assess the publication bias. All analyses will be performed via RevMan version 5.3.

Results

A total of 19 studies were included in the final analysis, 18 of which were eligible for quantitative analysis. As a high level of heterogeneity of included studies, random effect models were used. Both the theoretical and skill scores in flipped classroom students were higher than those in traditional lecture students (SMD = 8.33, 95% CI: 5.91–10.75, P < 0.001; SMD = 7.91, 95% CI: 5.86–9.91, P < 0.001, respectively). However, all included studies were of poor quality, and funnel plots indicated the presence of publication bias.

Conclusion

Flipped classrooms demonstrate potential in improving both theoretical knowledge and practical skills among medical students in clinical practice. Despite these promising results, the interpretation is limited by methodological shortcomings and potential publication bias in the included studies. Future research should focus on conducting high-quality, large-scale trials to validate these findings and explore their broader applicability.

Introduction

Clinical practice is a fundamental component of undergraduate medical education, enabling students to acquire critical clinical skills, medical knowledge, and interpersonal communication abilities [33]. In Chinese medical education, clinical practice serves as an indispensable stage for bridging theoretical knowledge with real-world healthcare settings. Its effectiveness is essential to fostering competent medical professionals capable of addressing practical challenges in healthcare delivery.

Flipped classroom courses, a term of blended learning introduced in 2007, reverse traditional teaching by requiring students to prepare key concepts at home and engage in collaborative activities during class time [13]. This approach is designed to facilitate knowledge application, analysis, and problem-solving [10]. The flipped classroom has shown promising outcomes in medical education, enhancing both theoretical learning and practical skills across various disciplines. For example, flipped classrooms in public healthcare significantly improved students’ knowledge, problem-solving abilities, and satisfaction compared to traditional lectures [15]. Similarly, a retrospective cohort study on a Doctor of Physical Therapy program in the U.S. demonstrated that students in flipped classroom settings achieved higher exam scores (Segal, Alteras, and Sandbank [32]). In addition, a randomized controlled trial (RCT) reported high levels of satisfaction and perceived learning among students in the flipped cohort section [32]. In nursing education, a meta-analysis found that flipped classrooms led to higher theoretical knowledge and skill scores among students [13]. However, some studies suggest mixed results. In emergency medicine residency programs, a randomized crossover study found that flipped classrooms were not superior to traditional lectures [30]. In ophthalmology clerkship, although the flipped classroom approach improved students’ motivation, understanding, communication, and clinical thinking, some students reported challenges due to the increased preparation workload [34]. These findings highlight both the potential and the limitations of flipped classrooms, indicating the need for further research to explore their applicability in diverse educational contexts.

Despite the growing adoption of flipped classrooms, the lack of large-scale, prospective clinical studies limits the ability to draw definitive conclusions about their effectiveness in clinical practice teaching, particularly in Chinese medical education [3]. To address this gap, we conducted a meta-analysis focusing on Chinese medical students undergoing clinical practice, comparing the flipped classroom teaching method with traditional lecture-based methods in terms of primary outcomes such as improvements in theoretical knowledge and practical skills, as well as secondary outcomes including student satisfaction, learning motivation, and engagement.

Methods

Search strategy

This meta-analysis was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines [26]. A systematic search of related articles was carried out in the following electronic databases: MEDLINE (via Pubmed), Embase (via Ovid), the Cochrane Central Register of Controlled Trials (CENTRAL, via Ovid), the China National Knowledge Infrastructure (CNKI), the Wanfang Database, the Chinese Scientific Journals Database (VIP) and SinoMed. The search was updated to include studies published up to June 2023. Both Medical Subject Headings (MeSH) terms and free-text terms were used, including but not limited to ‘clinical medicine’, ‘students, medical’, and ‘medical student’. The publications in Chinese or English were retrieved. The detailed search strategy can be found in Supplementary file 1.

Study selection

The inclusion and exclusion criteria for selecting studies are detailed in the Table 1 below.

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Screening and methodological quality assessment

Two researchers independently screened all the retrieved articles based on title and abstract, and then removed duplicated studies. Finally, researchers read full texts to make the final decision. A discussion was conducted to reach a consensus, otherwise the third researcher was involved to assess the selection based on the inclusion and exclusion criteria.

Methodological quality assessments of the included studies were conducted using the Cochrane Risk of Bias tool for randomized trials (available from: https://training.cochrane.org/handbook/current/chapter-08), which was the recommended tool for use in Cochrane Reviews, including evaluation of bias of randomization process, intended interventions, missing outcome data, measurement of the outcome and the selection of the reported result.

Data extraction

For all included studies, two researchers extracted data using a self-developed data extraction form. The extracted information included article information (authors, publication year and country or region), study information (study design, methods, study period, sample size and baseline) and outcomes.

Data analysis

The outcomes for the qualitative analysis included, continuous data, weighted mean differences (WMD) and 95% confidence interval (CI), which were used for data synthesis to compare them. The Cochran Q test and the I2 statistic were used for heterogeneity analysis. P ≥ 0.1 in Cochran Q test or I2 value < 50% was taken as acceptable heterogeneity, and the fixed effect model was used, otherwise a random effect model was applied. As the included studies expressed high heterogeneity, we used random effect models and did the systematic review. Furthermore, the funnel plots were used to assess the publication bias, evidence of asymmetry, and other small study effects. All analyses were conducted via RevMan version 5.3.

Results

Literature search results

A total of 2976 records were identified through all databases. Based on the title and abstract, records that did not meet the inclusion criteria were excluded (n = 2339). After removing the duplicated articles, 297 studies were included and full-text reviews were conducted. In this process, 220 records were further excluded as the participants were not undergraduate students or the settings were not hospitals (i.e., not clinical practice). Studies that combined flipped classroom and other interventions were also deleted (n = 46). In addition, we excluded another 12 records that lacked related outcomes, not RCT, or lacked full text. Finally, a total of 19 studies were included in the final analysis [1, 4, 5, 9, 11, 19,20,21,22, 24, 25, 28, 29, 34, 36, 37, 39, 41, 45]. See Table 2; Fig. 1 for a flow diagram of all the selected articles.

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General study characteristics

The characteristics of the included studies are presented in Table 2. Among all the 19 articles, 18 of them were published in Chinese and in Chinese publications, and the remaining one (Tang Fen, 2017) was published in English. Various subjects were included in this research, including hepatobiliary surgery, respiratory medicine, hematology, et al. All researchers indicated that the study type was an RCT, with a flipped classroom as the intervention and a traditional lecture as the control, although the duration of the intervention varied. The sample sizes of these studies ranged from 30 to 240, and the total merge sample size was 1562, with 779 in the intervention group (flipped classroom) and 783 in the control group (traditional lecture).

Meta-analysis results

All studies reported theoretical knowledge scores, with 18 presenting the data as continuous variables and one using a categorical variable. Consequently, we combined the results from the 18 studies, as shown in Fig. 2. The final analysis included a total of 1,460 participants: 728 in the flipped classroom group and 732 in the traditional lecture group. Among these 18 studies, 15 studies reached consistent results that the theoretical knowledge scores of flipped classroom group were significantly higher than those in the traditional lecture group, whereas another 3 studies showed the same trend, without statistical significance. As a high level of heterogeneity was detected among these 18 studies (I2 = 98%, P < 0.001), a random effect model was used. The pooled effect size had a significant difference between the two groups (SMD = 8.33, 95% CI: 5.91–10.75, P < 0.001). As for the research that described the outcomes as a categorical variable (Gu Liufang, 2018), the proportion of students whose scores were over 80 in the intervention group was higher than that in the control group, even though there were no significant differences.

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Figure 3 presents the results of the skill scores. Ten studies evaluated students’ practical skills after the intervention, with a total of 898 participants included in the final analysis—449 in each group. From this result, all the researchers consistently demonstrated a positive effect of the intervention. Similar to the heterogeneity test in theoretical knowledge scores, the level of heterogeneity was also high (I2 = 93%, P < 0.001), and a random effect model was applied. The pooled effect size had a significant difference between the two groups (SMD = 7.91, 95% CI: 5.86–9.91, P < 0.001).

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Risk of bias

According to Cochrane Risk of Bias tool for randomized trials, we evaluated the risk of bias of included studies based on random sequence generation (selection bias), allocation concealment (selection bias), blinding of participants and personnel (performance bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), selective reporting (reporting bias) and other bias. The outcomes were categorized as low risk (green ✔), unclear risk (yellow?), or high risk (red ✘). The result is presented in Fig. 4. Among the 19 studies included, four did not mention the randomization process, and one study [5] described the method as “randomized”, but participants were allocated based on the month, which does not meet the standard randomization method. Nevertheless, these studies were included because they were originally reported as RCTs in the literature, and the risk of bias was fully disclosed in the assessment. None of the studies demonstrated allocation concealment, and none of them mentioned blinding of outcome assessment. Only one study mentioned blinding of participants and personnel. Additionally, all studies reported all outcomes, and almost all studies, except one (Zhang et al. 2022a), reported comparable baseline information between the two groups.

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As for the risk of publication bias, visual inspection of funnel plots of both theoretical knowledge scores and skill scores indicated the presence of publication bias (Figs. 5 and 6). Besides publication bias, the asymmetries of funnel plots may also be caused by low-quality research and a high level of heterogeneity among included studies.

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Discussion

In this meta-analysis, a comprehensive literature search for the comparisons of the flipped classrooms and the traditional lectures was performed, and 19 records were included. We concluded that the students participating in the flipped classroom intervention presented much higher theoretical scores and skills scores compared to students who had undergone traditional lectures.

The traditional teaching method has primarily been lecture-based, making it teacher-centered and teacher-dominated [43], with knowledge transfer being one-way and passive. Studies have shown that learners forget 80% of the information within eight weeks (Sadeghi, Sedaghat, and Sha Ahmadi [31]. As the traditional method is not efficient and not suitable for every student, to overcome the limitations, scholars explored other teaching methods that allowed students to be more involved in classes in an active way [6]. Contrary to the traditional lecture method, the flipped classroom is a student-centered approach [17]. Generally, students are able to access teaching materials, usually videos, before class and can preview them again and again. The class time is always used for question & answer sessions, discussion, and case analysis et al. [17]. In this way, the flipped classroom is inverted to the traditional classroom, and the teachers in the flipped classroom play the role of observers and guides of activities instead [17]. In a flipped classroom, there is a more dynamic and active atmosphere for teachers to deliver knowledge and students to absorb it.

Our meta-analysis supports the positive impact of the flipped classroom on theoretical knowledge scores, consistent with findings from previous studies across various health science disciplines [13]. Similar results have been observed in nursing [14] and clinical medicine [38] programs, both for undergraduate [44] and postgraduate [30] students. Specifically, we found that flipped classrooms contributed significantly to improved theoretical scores in clinical practice settings. Flipped classrooms provide more flexible learning resources, enabling students to access materials anytime and anywhere [8]. Additionally, the ability to review content repeatedly enhances understanding [12]. The active classroom environment fosters more direct interaction between students and instructors, which can help reinforce learning and allow for immediate feedback [7].

Besides the theoretical scores, we also analyzed the skill scores of the students, revealing that the skill scores of students in flipped classroom groups had a significant increase as well. Clinical practice, including clerkships and internships, is an essential part of clinical medicine student cultivation, and flipped classrooms have been successfully implemented in this context (Khanittanuphong, Iamthanaporn, and Bvonpanttarananon [18] Wagoner et al. [35, 40]. Previous studies have shown that flipped classrooms can effectively enhance clinical skill development. For example, in a comparable study, researchers evaluated the effectiveness of flipped classrooms in clinical skill teaching, showing that students in flipped classroom cohort sections presented higher skill scores in multiple physical examination items [42]. Similar to theoretical score results, students in flipped classroom cohort sections gained more freedom and flexibility in learning, which means more opportunities to learn effectively [23]. Students also indicated their preference for the flipped classroom approach in some studies, reporting that they had high engagement and satisfaction in class, which could be useful for skill acquisition (Chan, Botelho, and Wong [2]. However, there are also controversial results, Ali Kaplan et al. (Kaplan, Özdemir, and Kaplan [16] carried out a single-center, single-blind parallel-group RCT on nursing students, suggesting no statistically significant elevation in the clinical practice skills of students receiving flipped classroom intervention compared with those of the control group. Despite that, students in this study also reported that flipped classroom promoted their learning motivation [16] and reduced exam anxiety. In this way, the flipped classroom can be used as an alternative method for clinical practice skill teaching.

Given the inconsistent results of previous studies, researchers were looking for the influential factors for the effectiveness of flipped classroom applications. Janique Oudbier et al. [27] concluded 6 factors, including student characteristics (consisting of the sub-factors self-regulated learning skills, prior knowledge, and learning attitude), teacher characteristics, implementation, task characteristics, out-of-class activities, and in-class activities. Specifically, students have a negative attitude towards flipped classrooms; the need for more prior knowledge and the requirement to invest additional time and resources may negatively impact the effectiveness of flipped classrooms [27]. This can be explained by the results in some studies that some students may find flipped classroom preparation a burden and stressful [34]. For students that are use to traditional lectures, they may complain about the more time and energy invested in flipped classroom modules [12]. There are studies reported that the videos previewed before class cannot be too long and should be restricted to 20 min, which could be acceptable for most students [12]. The burden of the flipped classroom may give to students may be one of the reasons why the flipped classroom approach cannot get positive feedback from students in some of the studies.

Strengths and limitations

This meta-analysis has several strengths. It represents the first systematic review and meta-analysis focusing on the effectiveness of flipped classrooms among Chinese clinical medicine students undergoing clinical practice, filling a gap in the existing literature that primarily emphasizes theoretical courses or other populations. Additionally, the study adopted a comprehensive approach by systematically searching and synthesizing relevant studies, ensuring robust and credible outcomes. These findings offer valuable insights that can serve as a reference for improving teaching practices and advancing research in clinical medical education, particularly in the Chinese context.

Nonetheless, several limitations must be acknowledged. The included studies generally exhibited low methodological quality, with few reporting randomization methods or blinding and none mentioning allocation concealment, which raises concerns about selection bias. There was also considerable heterogeneity among the studies, and publication bias was suggested by funnel plots for both theoretical knowledge scores and skill scores. Another limitation lies in the inconsistent measurement tools used to assess theoretical and skill outcomes, as these were self-designed by researchers without standardized criteria, potentially compromising comparability. Moreover, the focus of this meta-analysis was restricted to objective outcomes, such as knowledge and skill scores, while subjective aspects like student satisfaction, engagement, and preferences were not addressed. Although subjective outcomes are inherently more challenging to measure due to the lack of uniform instruments, their inclusion in future research could provide a more holistic evaluation of the flipped classroom model. Lastly, as all included studies were conducted within the Chinese population, the generalizability of the findings to other educational or cultural settings remains limited.

As a student-centered approach, the flipped classroom has been widely applied in education nowadays. Compared with students with traditional lectures, our results revealed that the student given to flipped classroom intervention presented much higher theoretical scores and skills scores. However, these findings should be interpreted cautiously due to the mentioned limitations. Future studies should prioritize high-quality RCTs with standardized assessment tools and explore subjective outcomes such as student satisfaction. Multicenter and cross-cultural research is also recommended to validate and generalize these results.

Data availability

The data analyzed in this meta-analysis were obtained from published studies, all of which are publicly available in academic databases.

References

Cao X, Lu J, Tang X, Li L. The application of case-based flipped Classroom based on we chat platform in the clinical teaching of gastrointestinal surgery. Chin Med Mod Distance Educ China. 2022;20(15):21–4.

Chan E, Botelho MG, Wong GTC. A flipped classroom, same-level peer-assisted learning approach to clinical skill teaching for medical students. PLoS ONE. 2021;16(10):e0258926.

Chen F, Lui AM, Martinelli SM. A systematic review of the effectiveness of flipped classrooms in medical education. Med Educ. 2017;51(6):585–97.

Chen J, Li L. Flipped Classroom in Hepatobiliary surgery teaching for undergraduate students. China Continuing Med Educ. 2017;9(29):15–7.

Chen Y, Xu Z, Liao S, Zhang X, Wu R, Yao B. Application of Flipping Classroom based on micro-lecture in clinical practice teaching of Neurology. China Health Ind. 2020;17(13):158–60.

Della Ratta CB. Flipping the classroom with team-based learning in undergraduate nursing education. Nurse Educ. 2015;40(2):71–4.

Galway LP, Corbett KK, Takaro TK, Tairyan K, Frank E. A novel integration of online and flipped classroom instructional models in public health higher education. BMC Med Educ. 2014;14:181.

Giuliano CA, Moser LR. Evaluation of a flipped drug literature evaluation course. Am J Pharm Educ. 2016;80(4):66.

Gu L, Tian J, Cui X, He A, Cao X. Application of Clinical Teaching Mode based on flipping class in clinical practice teaching of Hematology Department. Med Educ Res Pract. 2018;26(04):701–04.

Han F. Level of consistency between students’ self-reported and observed study approaches in flipped classroom courses: how does it influence students’ academic learning outcomes? PLoS ONE. 2023;18(6):e0286549.

Han S, Gao F. Application of flipped Classroom based on internet + in clinical teaching. China Continuing Med Educ. 2022;14(18):103–07.

Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38.

Hu R, Gao H, Ye Y, Ni Z, Jiang N, Jiang X. Effectiveness of flipped classrooms in Chinese baccalaureate nursing education: a meta-analysis of randomized controlled trials. Int J Nurs Stud. 2018;79:94–103.

Joseph MA, Roach EJ, Natarajan J, Karkada S, Cayaban ARR. Flipped classroom improves Omani nursing students performance and satisfaction in anatomy and physiology. BMC Nurs. 2021;20(1):1.

Kang HY, Kim HR. Impact of blended learning on learning outcomes in the public healthcare education course: a review of flipped classroom with team-based learning. BMC Med Educ. 2021;21(1):78.

Kaplan A, Özdemir C, Kaplan Ö. The Effect of the flipped Classroom Model on Teaching Clinical Practice skills. J Emerg Nurs. 2023;49(1):124–33.

Kazeminia M, Salehi L, Khosravipour M, Rajati F. Investigation flipped classroom effectiveness in teaching anatomy: a systematic review. J Prof Nurs. 2022;42:15–25.

Khanittanuphong P, Iamthanaporn K, Bvonpanttarananon J. The impact of the transition from flipped classroom to online lectures on learning outcomes and student satisfaction in a rehabilitation medicine clerkship during the COVID-19 pandemic. BMC Med Educ. 2022;22(1):885.

Kou H, Gao D, Wang H, Li Q, Liu X, Fan B, Jiang W, Han J, Zhang C, Deng J. Application of case-based learning together with flipped classroom teaching methods in electrocardiogram practice teaching through WeChat. Chin J Diagnostics(Electronic Edition). 2018;6(04):281–85.

Lei Z. Analysis of case-based Teaching Method of two Micro and one flip in ECG practice teaching. China Health Ind. 2020;17(25):156–58.

Li H, Chen W, Wei H, Xiong Y, Zhan H, Jing X. Application of flipped Classroom based on WeChat platform in the Medicine Students teaching of Emergency Medicine. Med Teach University(Electronic Edition). 2019;9(06):25–30.

Li W, Liu J, Liu W, Han Y, Zhang L. The application of flipped Classroom Teaching Method based on Microlesson in burn Department. Continuing Med Educ. 2021;35(04):11–3.

Lin Y, Zhu Y, Chen C, Wang W, Chen T, Li T, Li Y, Liu B, Lian Y, Lu L, Zou Y, Liu Y. Facing the challenges in ophthalmology clerkship teaching: is flipped classroom the answer? PLoS ONE. 2017;12(4):e0174829.

Lu D, Zhang Y. 2021. Application and EExploration of flipped Classroom Teaching based on micro-lecture in Neurosurgery Clinical Practice. Diet Health(17): 292.

Ma L, Wang Y, Li M, Liu W, Yu G, Xie L. Application effect of flipped classroom teaching mode based on WeChat platform in nephrotic syndrome internship. Clin Res Pract. 2022;7(01):186–90.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(4):264–9. w64.

Oudbier J, Spaai G, Timmermans K, Boerboom T. Enhancing the effectiveness of flipped classroom in health science education: a state-of-the-art review. BMC Med Educ. 2022;22(1):34.

Pan J, Pang L, Cui J, Yang Y, Guo T, Li G. Application of flipped Classroom in Undergraduate Clinical Teaching of Respiratory Medicine. China Continuing Med Educ. 2021;13(24):21–5.

Pan K, Zhao X. Effectiveness analysis of flipped classroom tecching in internal medicine internship on WeChat platform. Electron J Clin Med Literature. 2019;6(73):15–6.

Riddell J, Jhun P, Fung CC, Comes J, Sawtelle S, Tabatabai R, Joseph D, Shoenberger J, Chen E, Fee C, Swadron SP. Does the flipped Classroom Improve Learning in Graduate Medical Education? J Grad Med Educ. 2017;9(4):491–96.

Sadeghi R, Sedaghat MM, Sha Ahmadi F. Comparison of the effect of lecture and blended teaching methods on students’ learning and satisfaction. J Adv Med Educ Prof. 2014;2(4):146–50.

Segal R, Alteras I, Sandbank M. Rapid response of transient acantholytic dermatosis to selenium sulfide treatment for pityriasis versicolor. Dermatologica. 1987;175(4):205–7.

Swing SR. The ACGME outcome project: retrospective and prospective. Med Teach. 2007;29(7):648–54.

Tang F, Chen C, Zhu Y, Zuo C, Zhong Y, Wang N, Zhou L, Zou Y, Liang D. Comparison between flipped classroom and lecture-based classroom in ophthalmology clerkship. Med Educ Online. 2017;22(1):1395679.

Wagoner K, Dempsey A, Wade J, Dunn F. Evaluation and management of early pregnancy: a flipped Classroom Case for OB/GYN Clerkship Students. MedEdPORTAL. 2023;19:11297.

Wang J, Wu Z, Li Y, Yuan F, Liu J, Tian Y, Pang H. The design and application of the flipped classroom teaching model based on precision teaching in clinical practice of neurosurgery. Chin J Med. 2020;55(05):575–77.

Wang W, Cai Y, Yu D, Xue K, Zhang D, Yang J. Application of flip classroom teaching mode based on micro-lecture in clinical practice teaching in department of otolaryngology-head and neck surgery. Int J Dermatology Venereol. 2019;43(3):178–80.

Wu YY, Liu S, Man Q, Luo FL, Zheng YX, Yang S, Ming X, Zhang FY. Application and evaluation of the flipped Classroom based on Micro-video Class in Pharmacology Teaching. Front Public Health. 2022;10:838900.

Xie S. Research on wechat platform combined with flipped classroom teaching mode in neurosurgery clinical practice teaching. China Health Ind. 2018;15(33):167–68.

Xu P, Chen Y, Nie W, Wang Y, Song T, Li H, Li J, Yi J, Zhao L. The effectiveness of a flipped classroom on the development of Chinese nursing students’ skill competence: a systematic review and meta-analysis. Nurse Educ Today. 2019;80:67–77.

Zhang L, Li P, and C. Liu. The application of flipped Classroom based on micro-lecture in endocrinology practice lesson. Chin Med Mod Distance Educ China. 2022a;20(08):6–8.

Zhang W, Gu J, Li F, Feng F, Chen H, Xing X, Liu L. The effect of flipped classroom in multiple clinical skills training for clinical interns on Objective Structured Clinical examinations (OSCE). Med Educ Online. 2022b;27(1):2013405.

Zhao B, Potter DD. Comparison of lecture-based learning vs discussion-based learning in Undergraduate Medical Students. J Surg Educ. 2016;73(2):250–7.

Zheng Z, Yuan S, Huang M, Liao J, Cai R, Zhan H, Yang Z, Xiong Y. Flipped Classroom Approach used in the training of Mass Casualty Triage for Medical Undergraduate Students. Disaster Med Public Health Prep. 2022;16(1):94–101.

Zhou Y, Wang G, He Z, Li H, Jing Q, and D. Yu. Comparative study of two teaching modes in radiation oncology teaching. Chin J Prim Med Pharm. 2022;29(8):1251–54.