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

Abstract

Objective

To employ big data mining to provide a visualization analysis of Case-Based Learning (CBL) application in Chinese and international medical education, with the aim of observing the potential applications of CBL.

Methods

All included literature was obtained from the Web of Science (WoS) core collection database, Chinese core periodicals database, Chinese Social Sciences Citation Index (CSSCI), Chinese Science Citation Database of China National Knowledge Infrastructure (CNKI), Wangfang Database, and CQVIP Database. CiteSpace software (6.1.6R6) was used to conduct an in-depth investigation from four perspectives: quantitative analysis of literature, network analysis of co-occurring authors, network analysis of co-occurring research institutions, keyword clustering and burst analysis.

Results

A total of 721 Chinese articles and 537 English articles were included, demonstrating an exponential growth trend. Notably, no author exhibited a prolific publication rate within a short timeframe. Bursting keywords in English literature encompassed topics related to students' learning, teaching curriculum, methods, and location. In contrast, Chinese literature focused on students' learning, teaching methods, courses, application fields as well as national policy and the Ministry of Education of the People’s Republic of China (MOE) guidance. The keyword clusters include research on care, community practice, special projects and groups, teaching methods, and capacity development of participants in English literature. For Chinese literature, the clusters include research national policy guidance, teaching reform, mode and evaluation and various disciplines.

Conclusion

CBL holds immense potential for implementation across diverse disciplines, community practices, and special projects within medical education. The practical application of CBL is continuously evolving in response to changing times and can be seamlessly integrated into different contexts influenced by environmental factors and policies.

Background

The core principle of CBL centers on the utilization of cases as foundational elements, problems as fundamental components, students as primary participants, and teachers as facilitators. Initially implemented in business management courses, CBL has now become a widely adopted pedagogical approach in medical education [1]. It encompasses various aspects such as teacher instruction [2], students' learning [3], case selection, and evaluation of teaching effectiveness [4]. By seamlessly integrating theoretical knowledge with clinical practical knowledge, CBL enhances students' clinical abilities and fosters critical thinking skills. Moreover, CBL serves as a prevalent instructional method within the Extension for Community Healthcare Outcomes (ECHO) project—an innovative videoconferencing initiative launched in May 2019 to provide online telementoring and CBL specifically focused on Intestinal failure [5]. Similarly, CBL is extensively employed in China, often alongside other teaching methodologies [6].

However, currently there is a dearth of literature reviews comparing CBL in Chinese and international medical education, as well as a lack of retrospective studies, making it challenging to comprehend the current state of CBL’s application. To address these gaps, this study employs big data mining to provide a visualization analysis of CBL application in Chinese and international medical education by collecting and analyzing an extensive number of papers from various databases including WoS core collection database, Chinese core periodicals database, CSSCI database, CNKI, Wangfang Database, and CQVIP Database. Through literature visualization analysis and critical review techniques, key areas for CBL application in both contexts are identified. The comprehensive review utilizes the CiteSpace software (6.1.6R6), which is specifically designed for scientometrics and data visualization purposes. This information visualization software, Developed using Java language, offers wide applicability while objectively reflecting the characteristics, patterns, and distribution within related fields [7]. This paper applies CiteSpace software to analyze four perspectives: quantity analysis of literature; network analysis of co-occurring authors; network analysis of co-occurring research institutions; keywords clustering and burst analysis. Subsequently, this review focuses on highlighting similarities and differences in applied research content regarding CBL in medical education between China and other countries internationally. Based on the aforementioned review and analysis findings, a novel knowledge-oriented framework is proposed with the ultimate goal being to enhance the effective implementation of CBL in medical education (Fig. 1).

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Review and analysis methodology

To investigate the current advancements in CBL applications within Chinese and international medical education, a comprehensive literature analysis was conducted on publications in both Chinese and English languages, English-language literature to represent international medical education.

Chinese literature search method

In this study, the Chinese core periodicals database, CSSCI database, and Chinese Science Citation Database of CNKI, Wangfang Database and CQVIP Database were utilized as statistical sources for Chinese literature data. The retrieval time was set from the database construction until October 27, 2023. The retrieval strategy involved focusing on main topics in CNKI and Wanfang Database: Topics = (case teaching[案例教学] + /or CBL) AND (medicine[医学]). For CQVIP Database, the retrieval strategy focused on title or keyword: title or keyword = (case teaching[案例教学] + CBL) AND (medicine[医学]). Initially, news reports, notices to contributors, newsletters, conferences, forums, and dissertations were excluded. Subsequently, a total of 190 articles from CNKI, 589 articles from Wanfang Database and 140 articles from CQVIP Database were retrieved. Finally, using NoteExpress software to eliminate duplicate publications in Chinese literature resulted in a final inclusion of 721 unique articles published between 1995 and 2023.

English literature search method

The WoS core collection database served as a statistical source for English literature data, with the retrieval time set from the database construction period until October 27, 2023. The retrieval strategy employed was (TS = ("Case-Based Learning" or "Case Based Learning")) AND TS = (medi*), while the search refinement language was limited to English. The literature type included both articles and review articles, resulting in a total of 537 articles retrieved. After eliminating duplicate papers using CiteSpace software, a final set of 537 valid papers were obtained, covering the time span from 1998 to 2023.

Software analysis method

Using CiteSpace 6.1.R6 software, we set the time span from 1998 to 2023 for English literature data and from 1995 to 2023 for Chinese literature data, with a partition length of 1 year for visualizing and analyzing node information such as author, institution, country, and keywords. The statistical analysis of document count was performed using Excel tables.

Literature analysis techniques

Publication trend analysis method

The publication quantity and growth trend in the field are clearly illustrated using curve diagrams and exponential growth equations.

Author contribution assessment

Applying Price's law to identify core authors who have made significant contributions in their respective fields, a high-producing author is defined as an individual who has published three or more papers.

Institutional co-occurrence analysis method

CiteSpace uses node size and centrality to reflect research hotspots in related fields. Node size indicates the number of publications issued by institutions, while the lines between nodes reflect the degree of cooperation between research institutions. Different colors represent different years, with warmer color, indicating more recent years.

Keyword analysis method

1. (1)

Keywords co-occurrence analysis method

In the keyword co-occurrence analysis, keywords were merged based on their relevance to the research content. Given that "medical education" ("医学教育"in Chinese), "Case-Based Learning," and "case teaching" ("案例教学"in Chinese) serve as search strategy terms, they were omitted from the tables of high-frequency and high-centrality keywords in both Chinese and English literature, as well as from the classification of keyword bursts and clusters. It is important to note that high-frequency keywords do not necessarily pinpoint research hotspots with precision. In the keyword co-occurrence analysis, nodes with high centrality are highlighted by purple rings, the thickness of which represents the centrality value. This visual representation underscores potential cross-disciplinary connections and nascent links within the research field.

2. (2)

Keywords burst analysis method

The term "keyword bursts" refers to a significant surge in the frequency of keyword occurrence, which enables the identification of cutting-edge content within the research field. In this study, we conducted a keyword bursts analysis to identify the top 25 keywords in both Chinese and English literature, which can be categorized into different groups based on their content.

3. (3)

Keywords clustering and time diagram

The CiteSpace software was used to cluster keywords, and Panthfinder and Pruning were applied to the merged network to generate keyword clustering network diagram and keyword time diagram, and the top 50 keywords by annual frequency were employed for constructing the keyword clustering networks. The keyword clustering can be categorized into different groups based on their content.

Data cleaning and hominization

Author names have been standardized by correcting typographical errors and using full names instead of initials. Country names and affiliations have been verified and standardized, with institutions mapped to their respective countries and affiliation discrepancies resolved. Keywords have been cleaned by removing duplicates and spelling errors, and grouped under consistent terminology.

Result

Publication trend

The number and trend of published papers in a specific field can serve as indicators of the developmental stage, research trends, and knowledge maturity within that field. The increasing trend in the number of published papers reflects the overall growth pattern observed in Chinese and English literature (Fig. 2). The exponential function best describes this growth with high goodness-of-fit values: y = 1E-136e0.157× for Chinese literature (R2 = 0.6242) and y = 5E-132e0.1515× for English literature (R2 = 0.946). These findings suggest that the publication trend in English literature aligns more closely with an exponential function than that in Chinese literature, demonstrating a higher degree of fit.

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According to the trend chart (Fig. 2), the application of CBL in medical education has undergone stages of initial, steady, and rapid development. The period from 1995 to 2006 marked the initial stage of CBL pedagogy, which the annual publication count did not exceed 10 papers. From 2007 to 2014, both Chinese and English literature experienced steady growth, with Chinese publications showing greater vigor than their English counterparts. Since 2015, CBL teaching has entered a stage of rapid development. Chinese literature peaked in 2021 with 79 articles, while English literature reached its zenith in 2022 with 86 articles.

Authors

The author knowledge map of Chinese and English literature was generated using CiteSpace software (Fig. 3). The analysis revealed that the network consisted of 532 nodes(N), 743 connections(E), and a density of 0.0053 for Chinese literature, while for English literature, there were 547 nodes, 371 connections, and a density of 0.0025. Overall, collaboration between researchers in Chinese and English literature was limited, with most studies being conducted independently. No author exhibited prolific publication output within a short timeframe. According to Price's law, we identified six high-producing authors in Chinese literature and ten in English literature (Table 1 provides detailed information). All these authors had collaborative groups in English literature (Fig. 3a), however, only Xiaohui Guan ("关晓辉"in Chinese), Ling Liu ("刘岭"in Chinese), and Yazhou Wu ("伍亚舟" in Chinese) had established their own research networks specifically within the domain of Chinese literature (Fig. 3b).

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Institution

Figure 4 shows that there were 382 nodes and 377 connections in the English publishing institution, with a density of 0.0052(Fig. 4a), and 384 nodes and 36 connections with a density of 0.0005 in Chinese publishing institutions (Fig. 4b). There are 5 institutions with the highest centrality, all of which are 0.01, while other institutions in English literature have a centrality of 0. In contrast, the centrality of all institutions in Chinese literature is 0, indicating less overall inter-agency cooperation. The institutions with a large number of publications are shown in Table 2.

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In English literature, the University of Toronto ranked first with 15 articles. It was followed by three institutions with 7 papers each: the University of California, San Francisco, the University of New Mexico, and Emory University. In Chinese literature, Beihua University Affiliated Hospital ("北华大学附属医院" in Chinese) ranked first with 11 papers.

Keywords analysis

Keywords co-occurrence

Table 3 displays the merged keywords, and the resulting keyword knowledge graph is depicted in Fig. 5. Table 4 lists the top 10 keywords by frequency and centrality. The co-occurrence analysis and chart reveal distinct high-frequency and high-centrality keywords in both the Chinese and the English literature. Although these keywords are commonly used in specific fields like nursing or clinical medicine, their application varies between the Chinese and English literatures. The English literature mainly concentrates on students' grades and course attitudes, whereas the Chinese literature emphasizes overall design and teaching reform.

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Keywords bursts

As depicted in Fig. 6a and b, the top 25 keywords in both the Chinese and the English literature were identified through keyword bursts analysis. Furthermore, based on the content found in both the English and the Chinese literature, these burst keywords can be categorized into four distinct groups, as presented in Table 5.

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In the domain of English literature, the initial category includes keywords associated with student learning, reflecting a sustained emphasis on this area throughout the literature search period, which spans from 2006 (with "instruction" as a key term and a burst intensity of 1.92) to 2020 (marked by "technology" with a burst intensity of 2.47). Furthermore, the literature continues to feature a steady stream of articles focused on student learning.

The second category encompasses keywords related to teaching courses, highlighting the positive impact of CBL on enhancing instruction across a variety of subjects. Notably, interprofessional education has shown the highest mutation intensity, with a value of 2.47. This trend began in 2014 and persisted until 2017, yielding several published papers so far.

The third category of keywords pertains to teaching methods, indicating the potential for implementing a diverse array of teaching approaches in conjunction with CBL. Significantly, the flipped classroom model has demonstrated the highest degree of evolution, with an intensity rating of 3.23, having been adopted in 2018 and prevailing during the period from 2020 to 2021.Over the past two years, there has been a marked evolution in the prominence of the terms "distance" and "social media," with a burst intensity of 2.31, observable since 2021.

The fourth category relates to geographical locations, such as the "United States" and "American college." The existing literature on this specific type of design is particularly relevant at the national level.

In Chinese literature, the first category of keywords is closely associated with national policies and the guidance provided by MOE, such as "curriculum ideology and politics" and "quality education". Among these, "curriculum ideology and politics" exhibits the highest intensity at 7.83, starting in 2020. This demonstrates its close alignment with national policies.

The second category of keywords pertains closely to the evaluation and methods employed in teaching, such as "teaching effectiveness," "flipped classroom," and "mind mapping." "Flipped classroom" and "mind mapping" emerged as prominent keywords in 2019.

The third category pertains to teaching courses and application fields, encompassing prominent keywords such as "clinical medicine," "practical teaching," "nursing teaching," "biochemistry," "evidence-based medicine," and "narrative medicine." These keywords are frequently encountered, aligning with the practicality of teaching.

Keywords clustering and time diagram

Figure 7a and b represent the cluster diagrams, while Fig 7c and d depict the time diagrams with red dots indicating keyword bursts. The clusters are coded starting from zero, where cluster #0 is the largest one that gradually decreases in size thereafter Table 6.

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The network consists of a total of 534 nodes connected by 1315 edges with a density value of 0.0092. In terms of English literature, the largest connected component comprises 472 nodes, accounting for 88% of the entire network. Modularity is measured at 0.8164, and the Weighted Mean Silhouette stands at 0.927. For Chinese literature, the network consists of 457 nodes and 577 edges, with a density of 0.0055. The maximum connection component comprises 324 nodes, accounting for 70% of the entire network. The Q value is calculated as 0.8481, while the S value stands at 0.9719. A Q value greater than 0.3 indicates significant clustering within the module structure, whereas an S value close to 1 signifies higher homogeneity in the network and increased reliability in clustering results when S reaches a threshold of 0.7. These findings highlight the significance of clustering modularity and its efficiency.

The 14 clusters in English literature can be categorized into four groups: (1)Research on care(2 clusters), including #0 care and #13 primary care.(2) Research on community practices and special projects and populations(3 clusters), including #1 community of practice, #10 project echo and #11 teacher education.(3)Research on teaching methods ( 5 clusters), including #2 blended learning, #4 evidence-based practice, #5 problem-based learning, #9 CBL and #12 game experiment.(4)Research on competence development of participants( 4 clusters), including #3 attitude, #6 clinical competence, #7 decision making and #8 clinical reasoning.

In contrast, the clustering content of Chinese literature can be classified into three categories: (1) Teaching applications related to national policy guidance (1 cluster),#10 Ideological and political teaching clustering.(2)Application of CBL in educational reform, methods and evaluation ( 6 clusters),including #0 teaching method, #1 case teaching, #2 teaching reform, #4 scenario simulation, #8 cross training, and #13 learning interest clustering. (3) Application of CBL across various disciplines(7 clusters), including #3 Basic medicine, #5 evidence-based medicine, #6 Nursing education, #7 experimental teaching, #9 doctor-patient communication, #11 General Medicine and #12 Biochemical cluster.

Discussion

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.

Conclusion

Based on the preceding discussion, we can draw the following conclusions:

1. (1)

The application of CBL in medical education, as in other natural sciences, shows exponential growth. However, due to the unique nature of teaching development, collaboration among researchers and institutions is limited, with most practices occurring within individual units, primarily contributed by universities and their affiliates.

2. (2)

Co-occurrence and keyword cluster analysis show that CBL has vast potential for implementation across various disciplines, community practices, and special projects in medical education.

3. (3)

The emergence of keywords suggests that the practical application of CBL is evolving with the times. It can be seamlessly integrated into different contexts influenced by environmental factors and policies, such as becoming an integral part of online courses during pandemics or in the 5G era.

4. (4)

In educational practice, CBL can be effectively combined with diverse teaching methods, such as flipped classroom approaches, PBL, LBL, and RBL.

Data availability

No datasets were generated or analysed during the current study.

References

Tsekhmister Y. Effectiveness of case-based learning in medical and pharmacy education: a meta-analysis. Electron J Gen Med. 2023;20(5):13315.

Heemsoth T, Boe L, Bükers F, et al. Fostering pre-service teachers' knowledge of 'teaching games for understanding' via video-based vs. text-based teaching examples. Phys Educ Sport Pedagogy. 2022;27(1):77–90.

Gehrke-Beck S, Petersen M, Herrmann W J, et al. Development of a project for interprofessional collaboration between medical and pharmacy students to improve medication safety in polypharmacy (PILLE). GMS J Med Educ. 2023;40(1):Doc3.

Gupta A, Singh S, Khaliq F, et al. Development and validation of simulated virtual patients to impart early clinical exposure in endocrine physiology. Adv Physiol Educ. 2018;42(1):15–20.

Winkler MF, Tappenden KA, Spangenburg M, et al. Learn Intestinal Failure Tele-ECHO Project: An innovative online telementoring and case-based learning clinic. Nutr Clin Pract. 2021;36(4):785–92.

Chen L, Tang X J, Chen X K, et al. Effect of the BOPPPS model combined with case-based learning versus lecture-based learning on ophthalmology education for five-year paediatric undergraduates in Southwest China. Bmc Med Educ. 2022;22(1):s12909–022–03514–4.

Li J, Chen C. CiteSpace: text mining and visualization in scientific literature. Capital University of Economics and Business Press: Beijing, China. 2016:149–52.

Yang D, Wang BQ, Jin ML, et al. The application and thinking of the three-dimensional teaching mode combined with CBL, PBL and Seminar -- The application of bedside teaching practice in 8-year clinical medicine respiratory department. Med Philos(B). 2013;34(10):85–7.

Telner D, Bujas-Bobanovic M, Chan D, et al. Game-based versus traditional case-based learning: comparing effectiveness in stroke continuing medical education. Can Fam Physician. 2010;56(9):e345–51.

Pan B, Zhou YD, Yao R, et al. Case-based sandwich teaching improves communication confidence of eight-year undergraduates: treatment of breast cancer. Med J Peking Union Med Coll Hosp. 2022;13(02):349–52.

Yang R, Shui YS, Wang Y, et al. Effect of integrated teaching mode of problem-based learning combined with case-based learning applied to clinical teaching of stomatology: a meta-analysis. Chin J Pract Stomatol. 2023;16(04):467–73.

Zheng PW, Ye JY, Lu YF, et al. Development and teaching application of trainee case database in clinical psychiatry virtual simulation system. Res Explor Lab. 2023;42(03):255–7+318.

He H, Xu J, Sun M, et al. WeChat app combined CBL in oral medicine clinical training: a review. Medicine (Baltimore). 2023;102(11):e33102.

Yan X, Zhu Y, Fang L, et al. Enhancing medical education in respiratory diseases: efficacy of a 3D printing, problem-based, and case-based learning approach. BMC Med Educ. 2023;23(1):512.

Song X, Elftman M. Professionalism in small group learning between face-to-face and virtual settings: a mixed-methods study. Int J Med Educ. 2023;14:36–42.

Ou Y, Zhan YX, Zhuang XB, et al. A bibliometric analysis of primary immune thrombocytopenia from 2011 to 2021. Br J Haematol. 2023;201(5):954–70.

Kühne-Eversmann L, Eversmann T, Fischer MR. Team- and case-based learning to activate participants and enhance knowledge: an evaluation of seminars in Germany. J Contin Educ Health Prof. 2008;28(3):165–71.

Zottmann J M, Horrer A, Chouchane A, et al. Isn't here just there without a "t" - to what extent can digital clinical case discussions compensate for the absence of face-to-face teaching?. GMS J Med Educ. 2020;37(7):Doc99.

Singh K, Bharatha A, Sa B, et al. Teaching anatomy using an active and engaging learning strategy. BMC Med Educ. 2019;19(1):149.

Lestari E, Rahmawatie DA, Wulandari CL. Does online interprofessional case-based learning facilitate collaborative knowledge construction? J Multidiscip Healthc. 2023;16:85–99.

Dettmer S, Barkhausen J, Volmer E, et al. White paper: radiology curriculum for undergraduate medical education in Germany and Integration into the NKLM 2.0. Rofo. 2021;193(11):1294–303.

Maia D, Andrade R, Afonso J, et al. Academic performance and perceptions of undergraduate medical students in case-based learning compared to other teaching strategies: a systematic review with meta-analysis. Educ Sci. 2023;13(3):13030238.

Grady ZJ, Gallo LK, Lin HK, et al. From the operating room to online: medical student surgery education in the time of COVID-19. J Surg Res. 2022;270:145–50.

Guerra F, Linz D, Garcia R, et al. The use of social media for professional purposes by healthcare professionals: the #intEHRAct survey. Europace. 2022;24(4):691–6.

Bennett P, Morton K. Nuclear medicine education via instagram: a viable method for informal lifelong learning. J Nucl Med Technol. 2021;49(2):175–7.

Li L, Liu X, Chen Z, et al. The application of a case-based social media-assisted teaching method in cariology education: comparative study. J Med Internet Res. 2021;23(8):e29372.

Williams A, Thomas E A, Bhatia A. WhatsApp mobile application as a learning tool for teaching dermatology to undergraduates. J Clin Diagn Res. 2022;16(9):WC5-WC8.

Furlan AD, Zhao J, Voth J, et al. Evaluation of an innovative tele-education intervention in chronic pain management for primary care clinicians practicing in underserved areas. J Telemed Telecare. 2019;25(8):484–92.

Hong S, Yu P. Comparison of the effectiveness of two styles of case-based learning implemented in lectures for developing nursing students’ critical thinking ability: a randomized controlled trial. Int J Nurs Stud. 2017;68:16–24.

Seymour R, Scher C, Frasso R, et al. Exposing the disability-related hidden curriculum in case-based learning: a qualitative study. Disabil Health J. 2023;16(4):101483.

Deeds SA, Dowdell KJ, Chew LD, et al. Implementing an opt-in eConsult program at seven academic medical centers: a qualitative analysis of primary care provider experiences. J Gen Intern Med. 2019;34(8):1427–33.

Strasser RP. Community engagement: a key to successful rural clinical education. Rural Remote Health. 2010;10(3):1543.

Katzman JG, Comerci G Jr, Boyle JF, et al. Innovative telementoring for pain management: project ECHO pain. J Contin Educ Health Prof. 2014;34(1):68–75.

Tosi LL, Rajah EN, Stewart MH, et al. The rare bone disease TeleECHO program: leveraging telehealth to improve rare bone disease care. Curr Osteoporos Rep. 2020;18(4):344–9.

Serhal E, Arena A, Sockalingam S, et al. Adapting the consolidated framework for implementation research to create organizational readiness and implementation tools for project ECHO. J Contin Educ Health Prof. 2018;38(2):145–51.

Sood A, Assad N, Jarrell W, et al. A virtual community-of-practice approach by rural stakeholders in managing pneumoconiosis in the USA: a cross-sectional analysis. Rural Remote Health. 2020;20(3):5784.

Wray A, Wolff M, Boysen-Osborn M, et al. Not another boring resident didactic conference. AEM Educ Train. 2020;4(Suppl 1):S113–21.

Kramer C, König J, Strauss S, et al. Classroom videos or transcripts? A quasi-experimental study to assess the effects of media-based learning on pre-service teachers’ situation-specific skills of classroom management. Int J Educ Res. 2020;103:101624.

Duckwitz V, Vogt L, Hautzinger C, et al. Students’ acceptance of case-based blended learning in mandatory interdisciplinary lectures for clinical medicine and veterinary public health. Vet Rec Open. 2021;8(1):e14.

Braeckman LA, Fieuw AM, Van Bogaert HJ. A web- and case-based learning program for postgraduate students in occupational medicine. Int J Occup Environ Health. 2008;14(1):51–6.

Mahnken AH, Baumann M, Meister M, et al. Blended learning in radiology: is self-determined learning really more effective?. Eur J Radiol. 2011;78(3):384–7.

Dai A, Wu LQ, Jacobs RC, et al. Implementation of a medical school elective course incorporating case-based learning: a pilot study. Med Sci Educ. 2020;30(1):339–44.

Lovasik BP, Rutledge H, Lawson E, et al. Development of a surgical evidence blog at morbidity and mortality conferences: integrating clinical librarians to enhance resident education. J Surg Educ. 2020;77(5):1069–75.

Salbach NM, Veinot P, Jaglal SB, et al. From continuing education to personal digital assistants: what do physical therapists need to support evidence-based practice in stroke management?. J Eval Clin Pract. 2011;17(4):786–93.

Katzman JG, Qualls CR, Satterfield WA, et al. Army and Navy ECHO pain telementoring improves clinician opioid prescribing for military patients: an observational cohort study. J Gen Intern Med. 2019;34(3):387–95.

Mcfee RM, Cupp AS, Wood JR. Use of case-based or hands-on laboratory exercises with physiology lectures improves knowledge retention, but veterinary medicine students prefer case-based activities. Adv Physiol Educ. 2018;42(2):182–91.

Evans GF, Brooks J, Collins L, et al. General practitioner educators on clinical debrief: a qualitative investigation into the experience of teaching third-year medical students to care. Teach Learn Med. 2023;36:1–10.

Dhanvijay AKD, Pinjar MJ, Dhokane N, et al. Performance of large language models (ChatGPT, Bing Search, and Google Bard) in solving case vignettes in physiology. Cureus. 2023;15(8):e42972.

Jiang Z, Zhu D, Li J, et al. Online dental teaching practices during the COVID-19 pandemic: a cross-sectional online survey from China. BMC Oral Health. 2021;21(1):189.

Akl EA, Kairouz VF, Sackett KM, et al. Educational games for health professionals. Cochrane Database Syst Rev. 2013;2013(3):Cd006411.

He R, Xie Y, Liu F, et al. Implementing case-based collaborative learning curriculum via webinar in internal medicine residency training: a single-center experience. Medicine (Baltimore). 2023;102(16):e33601.

Luxford JC, Cheng TL, Mervis J, et al. An opportunity to see the heart defect physically: medical student experiences of technology-enhanced learning with 3D printed models of congenital heart disease. Med Sci Educ. 2023;33(5):1095–107.

Da J, Ran Y, Pi M, et al. Application of mini-clinical evaluation exercise for assessing the integrated-based learning during physical diagnostic course. Biochem Mol Biol Educ. 2018;46(5):417–23.

Ludwig B, Turk B, Seitz T, et al. The search for attitude-a hidden curriculum assessment from a central European perspective. Wien Klin Wochenschr. 2018;130(3–4):134–40.

Miller MM, Slanetz PJ, Lourenco AP, et al. Teaching principles of patient-centered care during radiology residency. Acad Radiol. 2016;23(7):802–9.

Englander H, Patten A, Lockard R, et al. Spreading addictions care across Oregon’s rural and community hospitals: mixed-methods evaluation of an interprofessional telementoring ECHO program. J Gen Intern Med. 2021;36(1):100–7.

Baillargeon JP, St-Cyr-Tribble D, Xhignesse M, et al. Impact of an educational intervention combining clinical obesity preceptorship with electronic networking tools on primary care professionals: a prospective study. BMC Med Educ. 2020;20(1):361.

Malik R, Abbas JR, Jayarajah C, et al. Mixed reality enhanced otolaryngology case-based learning: a randomized educational study. Laryngoscope. 2023;133(7):1606–13.

Darras KE, Spouge RJ, De Bruin ABH, et al. Undergraduate radiology education during the COVID-19 pandemic: a review of teaching and learning strategies [Formula: see text]. Can Assoc Radiol J. 2021;72(2):194–200.

Chandran DS, Muthukrishnan SP, Barman SM, et al. IUPS physiology education workshop series in India: organizational mechanics, outcomes, and lessons. Adv Physiol Educ. 2020;44(4):709–21.

Crome M, Adam K, Flohr M, et al. Application of the inverted classroom model in the teaching module “new classification of periodontal and peri-implant diseases and conditions” during the COVID-19 pandemic. GMS J Med Educ. 2021;38(5):Doc89.

Consorti F, Borcea MC, Laca A, et al. Education of clinical reasoning in patients with multimorbidity: a scoping review and perspectives for technology-enhanced learning. Front Educ. 2023;8:1202360.

Dong D, Hou J, Wang JZ, et al. Evaluation and analysis of teaching effect of ideology and politics in Medical Immunology. Chin J Immunol. 2023;39(06):1185–8.

Zhang C, Cai XP, Chen YY, et al. Methods of cultivating students’ clinical thinking ability in Pathogenic Biology and Immunology teaching. J Pathogen Biol. 2022;17(10):1239–41.

Tan SF, Yan ZL, Chen J, et al. Application of follow-up theory course CBL and practice course PBL teaching method in clinical gynecological oncology. Basic Clin Med. 2021;41(02):301–3.

Guo QK, Zheng M, Xu Y, et al. Application of flipped classroom using WeChat platform combined with problem-based learning and case-based learning methods in clinical practice teaching of thoracicsurgery. Shanghai Med J. 2020;43(07):424–8.

Xin JG, Yang XH, Chen XF, et al. Teaching practice and effect evaluation of epidemiology in clinical related majors based on the simulation teaching method. Mod Prev Med. 2022;49(11):2101–6.

Yang XH, Zhang L, Zeng QJ, et al. Analysis of knowledge and attitude related to evidence-based medicine course in clinical medical students. Chin J Evid Based Med. 2013;13(07):810–5.

Shu QL, Feng J. Introducing, “scientific frontier” to improve the quality of college biochemistry teaching in classroom. Chem Life. 2020;40(03):454–7.

Shan YW, Wu KL, Sun YN, et al. Application of moral education online teaching of surgical nursing science based on the medical narrative concept in undergraduate nursing teaching. Chin Nurs Res. 2021;35(23):4260–4.