Application of integrated whole-course clinical learning combined with case-based learning in undergraduate otolaryngology clerkships

Abstract

Purpose

Lecture-based learning (LBL) and case-based learning (CBL) are widely used teaching methods across disciplines, especially in medical and health sciences education. However, both methods may fail to fully engage students’ intrinsic motivation for active participation. The aim of this study is to combine integrated whole-course clinical learning (IWCL) with CBL in the context of an undergraduate clerkship in otolaryngology.

Methods

A total of 79 undergraduate students participated in this project and were assigned to one of two groups. The first group received the IWCL combined with the CBL teaching model and was designated the IC group, whereas the second group received the LBL combined with the CBL teaching model and was designated the LC group. Differences between the two groups in terms of teaching effectiveness during the otorhinolaryngology clinical clerkship were evaluated using multiple outcome measures, including specialty physical examination proficiency level, admission note documentation quality, anatomical proficiency level, and satisfaction with the teaching model.

Results

Comparison of specialty physical examination proficiency between the IC and LC groups revealed no significant difference. However, the results suggest potential advantages of the IC approach across several key domains, including admission note documentation quality and level of anatomical proficiency. In addition, the students in the IC group achieved higher subject scores. Moreover, compared with the LC group, the IC group exhibited higher levels of satisfaction in dimensions.

Conclusions

The combined teaching model includes the strengths of CBL, emphasizing case analysis, interactive participation, and continuous clinical engagement. As a result, the IC group exhibited a clear advantage over the LC group in terms of overall teaching effectiveness.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12909-026-09871-8.

Introduction

The undergraduate otolaryngology clerkship is a crucial transitional phase for medical students, helping them transition from the classroom to the clinic [1]. It is a core component for strengthening the integration of theoretical knowledge and practical skills. Optimizing the teaching design at this stage not only enhances students’ clinical thinking but also subtly ignites their passion for the otolaryngology specialty, thereby influencing their future career paths.

The learning difficulties associated with otolaryngology surgery stem from the unique characteristics of the anatomical structures involved [2–4]:

1. Three-dimensional complexity: The three-dimensional distribution of the ossicular chain within the temporal bone and the hidden nature of the spheno-ethmoidal recess make it difficult to construct a spatial cognitive model from traditional 2D atlases. This often leads students into a ‘localization blind spot’ dilemma.

2. Structure‒Function Coupling: The precise alignment of hair cell cilia in the vestibule for balance sensation and the physical coupling of the tympanic cavity’s air space with auditory conduction require a simultaneous explanation of the dynamic relationship between morphology and function.

3. High-risk Neurovascular Areas: The millimeter-scale proximity of the vagus nerve and the internal jugular vein in the jugular foramen region indicates that misjudgment during a procedure can lead to serious complications. This often causes students to develop a sense of apprehension during early hands-on practice.

To address these learning difficulties, we have made extensive improvements to our undergraduate clerkship curriculum, which includes theoretical review, specialty physical examinations, outpatient shadowing, anatomical study, and writing admission notes. Since each curriculum subject has its unique characteristics, different teaching methods must be integrated to maximize students’ subjective initiative and enable them to apply theoretical knowledge to clinical practice more effectively, thereby improving their overall competence. To this end, we introduced the IWCL method on the basis of traditional CBL [5–7] and LBL [8] approaches.

IWCL is a comprehensive, practice-oriented educational approach designed to expose undergraduate students to the full trajectory of patient care. In this model, every stage of the clinical process—from outpatient consultation (including initial reception, collection of medical history, physical examination, diagnosis, assessment of hospitalization and surgical indications, and issuance of admission certificates) to inpatient management (comprehensive collection of medical history, detailed general and specialty physical examination, preparation of admission notes, and review of laboratory and imaging results) and finally to the surgical stage (participation in preoperative planning, observation of the operation, and postoperative review to consolidate knowledge of surgical procedures and anatomical structures)—are connected.

By guiding students to follow selected patients throughout their entire clinical course, the IWCL fosters a deep understanding of disease evolution, diagnostic reasoning, and therapeutic decision-making. The model emphasizes integrative learning, clinical thinking, and reflective practice, helping students transition from fragmented observation to holistic patient-centered competence.

Methods

Study design

The undergraduate medical education typically consists of a five-year program, including a one-year internship. Clinical clerkships are generally arranged in the fifth year of study. This research was designed as a controlled educational intervention conducted in a routine clinical teaching context. A total of 79 students, including 39 men and 40 women, participated in this project. The students were organized into preexisting clerkship groups in accordance with standard educational practices. Allocation to different groups on the basis of instructional approaches was performed using a computer-generated sequence (using a random number generator in Microsoft Excel) at the group level rather than at the individual level. The IC group (n = 39) received IWCL combined with CBL, whereas the LC group (n = 40) received CBL combined with LBL. Given that the groups were established within an authentic educational setting, allocation concealment was limited, and the blinding of the participants and instructors was not feasible. Details of the specific teaching methods are shown in Supplementary Table 1.

Assessment methods

The primary outcomes were the final examination scores for the following subjects: specialty physical examination, writing of the admission notes, anatomical proficiency, and theory. All the subject examinations had a maximum score of 100 points, except for the temporal bone anatomy test, whose maximum score was 20 points. In addition, the secondary outcomes included the specialty physical examination proficiency level, admission note documentation quality, anatomical proficiency level, and satisfaction with the teaching model. All the scales were divided into four levels according to the 4-point Likert scale [9]: very unskilled, unskilled, skilled, and very skilled. These levels were scored as 1, 2, 3, and 4 points, respectively.

A Specialty Physical Examination Proficiency Assessment scale, an Admission Note Documentation Quality Assessment scale, an Anatomical Proficiency Assessment scale, and a Satisfaction with the Teaching Model scale were developed on the basis of the relevant literature and expert consultation. Content validity was evaluated by a panel of three experts, each with a minimum of 10 years of experience, using the content validity index (CVI), with average CVI values ranging from 0.91 to 0.95. Internal consistency reliability was assessed using Cronbach’s alpha, which ranged from 0.93 to 0.94 (Supplementary Table 2).

Questionnaires

At the end of the undergraduate clerkship, all the participants anonymously completed a teaching satisfaction questionnaire to evaluate the effectiveness of the two teaching methods. The survey included the following evaluation items: (a) deepened the mastery of fundamental knowledge in otorhinolaryngology, (b) inspired enthusiasm for learning, (c) improved class participation, (d) improved classroom engagement, (e) enhanced oral expression ability, (f) enhanced self-learning ability, (g) improved clinical operational skills, (h) enhanced the ability to analyze and solve problems, (i) enhanced the ability to consult the literature and solve problems, (j) strengthened clinical thinking ability, k. cultivated scientific research thinking ability, l. enhanced doctor–patient communication skills, m. strengthened team communication and collaboration skills, n. increased confidence in future clinical work, and o. satisfaction with the teaching approach. Each item was rated on a 4-point Likert scale: 1 – very unsatisfied, 2 – unsatisfied, 3 – satisfied, and 4 – very satisfied. Higher scores indicate greater perceived effectiveness and satisfaction with the teaching method.

Statistical analysis

GraphPad Prism 10.6 (GraphPad Software, San Diego, CA, USA) was used for statistical analyses. Normally distributed continuous data were presented as the mean ± SD. Continuous variables were analyzed using the unpaired t test, whereas ordinal categorical variables were compared using the Mann–Whitney U test. Because the Likert-scale variables were ordinal, the data are summarized as medians and interquartile ranges (IQRs). Group comparisons were performed using Mann–Whitney U tests. Effect sizes are reported as Hodges–Lehmann median differences with 95% confidence intervals. P values were adjusted for multiple testing using the Benjamini–Hochberg false discovery rate procedure. All the statistical tests were two-sided, and p < 0.05 was considered to indicate statistical significance.

Results

Comparison of specialty physical examination proficiency levels

A comparative analysis of specialty physical examination proficiency between the IC group and the LC group revealed no significant difference in performance (median [IQR]: 3.04 [2.52–3.39] vs. 2.85 [2.38–3.17]; Mann–Whitney U = 98.50; adjusted p = 0.27). The Hodges–Lehmann median difference (IC-LC) was 0.16 (95% CI, -0.18 to 0.46) (Fig. 1a–p). However, the improvement trend was consistent across certain skill domains; the students in the IC group (3.51 ± 0.51) achieved higher proficiency scores (p = 0.03) in examinations of the auricle, external auditory canal, and tympanic membrane than those in the LC group did (3.18 ± 0.68). Moreover, compared with those in the LC group (3.10 ± 0.67), students in the IC group (3.46 ± 0.55) exhibited greater mastery (p = 0.02) in the tuning fork test. However, compared with those in the LC group, students in the IC group did not exhibit an obvious improvement in the visual distribution of proficiency levels across other specialty physical examination items.

Fig. 1.

Comparison of Specialty Physical Examination Proficiency level a Examination of auricle, external auditory canal, and tympanic membrane b Tuning fork test, c: Examination of external nose and nasal vestibule d Examination of superior, middle, and inferior nasal conchae e Examination of superior, middle, and inferior nasal meatuses f Examination of olfactory cleft and nasal septum g Examination of nasopharyngeal roof, pharyngeal recess, torus tubarius, pharyngeal opening of auditory tube, and choanae h Examination of isthmus of fauces (including uvula, free margin of soft palate, palatoglossal arch, palatopharyngeal arch, and dorsum of tongue) i Examination of tonsils and posterior pharyngeal wall, j: Examination of piriform recess and postcricoid region k Examination of tongue base, epiglottis, vallecula, and aryepiglottic folds l Examination of supraglottic region m Examination of glottic region n Examination of subglottic region o Examination of neck (including thyroid gland) p Overall proficiency in ENT physical examination

Assessment of admission note documentation quality

The results of the assessment of admission note documentation of the students in the IC and LC groups are presented in Fig. 2. Across the evaluated domains, the performance of the students varied according to the teaching methods. Compared with those in the LC group, the students in the IC group achieved higher satisfaction scores (median [IQR]: 3.21 [3.17–3.29] vs. 2.91 [2.85–3.06]); Mann–Whitney U = 12.50; adjusted p < 0.01). The Hodges–Lehmann median difference (IC-LC) was 0.30 (95% CI, 0.18 to -0.38). With respect to the writing of the present illness history (c), the mean score of the students in the IC group was 3.21 ± 0.47, whereas the mean score of the students in the LC group was 2.95 ± 0.55. In the recording and documentation of vital signs and findings from the eight major system examinations (e), the students in the IC group scored higher (3.51 ± 0.51) than those in the LC group did (3.00 ± 0.78) (p = 0.04). Compared with those in the LC group (2.85 ± 0.66), students in the IC group performed better in the documentation of otoscopic (electric otoscope) examination findings (f), with scores of 3.21 ± 0.52 (p = 0.02). Moreover, on the documentation of the tuning fork test results (g), students in the IC group scored higher (3.23 ± 0.54) than those in the LC group did (2.85 ± 0.70) (p = 0.01). There were also improvements in the documentation of oropharyngeal examination (with a tongue depressor) findings (IC-LC: 3.21 ± 0.52 vs. 2.83 ± 0.84; p = 0.04), documentation of indirect laryngoscopy findings (IC-LC: 3.18 ± 0.51 vs. 2.83 ± 0.78; p = 0.03), and documentation of neck examination findings (IC-LC: 3.28 ± 0.46 vs. 2.90 ± 0.81; p = 0.03) among the students in the IC group. Overall, these results suggest that the IC approach may result in the improvement of most practical documentation skills and present a more effective method for improving both the completeness and accuracy of clinical documentation among students. However, no differences were found for the other items.

Fig. 2.

Admission Note Documentation Quality Assessment a Overall quality of admission Notes writing b Writing of chief complaint c Writing of present illness history d Others: including past history, personal history, marital and reproductive history, and family history e Recording and documentation of vital signs and findings from the eight major system examinations f Documentation of otoscopic (electric otoscope) examination findings g Documentation of tuning fork test results h Documentation of anterior rhinoscopy findings i Documentation of oropharyngeal examination (with tongue depressor) findings j Documentation of indirect nasopharyngoscopy findings k Documentation of indirect laryngoscopy findings l Documentation of neck examination findings m Documentation of admission condition assessment n Documentation of preliminary diagnosis

Comparison of anatomical proficiency levels

The performance of the students in the IC group was compared with that of the students in the LC group across several anatomical or functional parameters, including the auricle, EAM, TM, MAC, TT, SS, TA, ER, OC, OW/RW, CT/TS, TOET, Hypotympanum, Cochlea/SC, and OP. Overall, compared with those in the LC group, the students in the IC group indicate that consistently higher or equivalent values for most parameters (Fig. 3). Compared with those in the LC group, students in the IC group achieved higher satisfaction scores (median [IQR]: 2.95 [2.77–3.44] vs. 2.65 [2.48–3.08]; Mann–Whitney U = 62; adjusted p = 0.04). The Hodges–Lehmann median difference (IC-LC) was 0.31 (95% CI, 0.04 to 0.61). For instance, in the tympanic membrane measurement, students in the IC group had higher scores (3.44 ± 0.55) than those in the LC group (3.13 ± 0.65; p = 0.04), indicating improved performance. Similar trends were observed for TT (IC-LC: 2.67 ± 0.77 vs. 2.28 ± 0.64; p = 0.02), SS (IC-LC: 2.77 ± 0.67 vs. 2.43 ± 0.64; p = 0.03), TA (IC-LC: 2.95 ± 0.65 vs. 2.53 ± 0.75; p = 0.01), OC (IC-LC: 3.56 ± 0.55 vs. 3.00 ± 0.71; p < 0.01), TOET (IC-LC: 2.67 ± 0.77 vs. 2.28 ± 0.64; p = 0.03), OW/RW (IC-LC: 3.49 ± 0.51 vs. 2.88 ± 0.76; p < 0.01), and Cochlea/SC (IC-LC: 3.49 ± 0.60 vs. 3.08 ± 0.73; p = 0.01), in which the students in the IC group exhibited higher or more uniform measurements, suggesting enhanced accuracy and consistency. Conversely, scores for other parameters, such as the auricle, EAM, MAC, and others did not significantly differ between the two methods. Overall, these findings suggest that the IC approach was associated with improved performance for parameters related to structural detail and auditory pathway measurements compared with the LC approach.

Fig. 3.

Comparison of Anatomical Proficiency Level. EAM: External Acoustic Meatus, TM: Tympanic Membrane, MAC: Mastoid Air Cells, TT: Tegmen Tympani, SS: Sigmoid Sinus, TA: Tympanic Antrum, ER: epitympanic recess, OC: Ossicular Chain, OW: Oval Window, RW: Round Window, CT: Chorda Tympani Nerve, TS: Tympanic Segment of Facial Nerve, TOET: Tympanic Ostium of Eustachian Tube, SC: Semicircular Canals, OP: Overall Proficiency

Comparison of subject scores

In this study, we compared the academic performance of two cohorts of students who were exposed to different teaching methodologies across multiple subjects. The findings revealed differences in several performance domains (Fig. 4). The students in the IC group achieved higher scores on specialty physical examination skills than those in the LC group did (IC-LC: 89.18 ± 4.26 vs. 85.22 ± 4.22; Welch’s t test: t(77) = 4.14, adjusted p < 0.01). The mean difference was 3.95 points (IC-LC; 95% CI, 0.21 to 0.59). Furthermore, the performance of the students in the IC group on writing admission notes was improved (IC-LC: 90.95 ± 2.64 vs. 86.95 ± 3.41; Welch’s t test: t(73) = 5.84; adjusted p < 0.01). The mean difference was 4.00 points IC-LC and 95% CI was 2.6 to 5.4. Similarly, the students in the IC group achieved higher anatomy scores (IC-LC: 15.97 ± 2.12 vs. 12.63 ± 4.10; t(59) = 4.58; adjusted p < 0.01), and the mean difference was 3.35 points (IC-LC; 95% CI, 1.9 to 4.8).

Fig. 4.

Comparison of Subjects’ Scores SPES: Specilty Physical Examination Scores, ANDS: Admission Notes Documentation Scores, AS: Anatomy Scores, TS: Theoretical Scores

In contrast, no significant difference was observed in the theoretical examination scores between the two groups (IC-LC: 88.92 ± 8.52 vs. 85.15 ± 9.97; t(76) = 1.81; adjusted p = 0.07). The mean difference was 3.77 points (IC-LC; 95% CI, -0.38 to 7.9). This outcome may be attributed to the fact that undergraduate clinical clerkships are conducted after the completion of all theoretical coursework. Consequently, students’ theoretical knowledge retention depends primarily on the structure and quality of prior classroom teaching. Although clinical clerkships offer opportunities to review theoretical content, the limited duration of these clerkships typically leads to an emphasis on practical, case-related learning rather than on comprehensive theoretical reinforcement. In addition, the large variability in the theoretical scores across both groups, which is evident from the error bars, is one of the reasons for the absence of a significant difference between the two groups.

In summary, the performance of the students in the IC group in terms of specialty physical examination, admission note documentation, and anatomical proficiency significantly improved, whereas theoretical knowledge remained comparable between the groups.

Comparison of satisfaction

The teaching satisfaction survey was completed by 79 undergraduate students, yielding a 100% response rate. The analysis of the survey results revealed a difference between the IC group and the LC group (Fig. 5). The students in the IC group reported higher overall satisfaction with the teaching method than those in the LC group did (median [IQR]: 3.49 [3.44–3.59] vs. 3.13 [3.08–3.15]); Mann–Whitney U = 10, adjusted p < 0.01). The Hodges–Lehmann median difference (IC-LC) was 0.39 (95% CI, 0.31 to 0.47). These findings suggest that the IC approach was more positively received by the students and contributed to an enhanced learning experience (Supplementary Table 3).

Fig. 5.

Comparison of Satisfaction for the Teaching Model: a deepened mastery of fundamental knowledge in otorhinolaryngology b inspired enthusiasm for learning c improved class participation d improved classroom engagement e enhanced oral expression ability f enhanced self-learning ability g improved clinical operational skills h enhanced the ability to analyze and solve problems i enhanced the ability to consult the literature and solve problems j strengthened clinical thinking ability k cultivated scientific research thinking ability l enhanced doctor–patient communication skills m strengthened team communication and collaboration skills n increased confidence in future clinical work o satisfaction with the teaching approach

Discussion

LBL is among the oldest and most widely used teaching methods across disciplines, especially in medical and health sciences education, where a large body of theoretical knowledge must be transmitted efficiently [10]. A recent study compared the effectiveness of active learning and a hybrid lecture-based method for teaching fundamental radiology concepts to second-year medical students. The findings unequivocally revealed that,, compared with the active learning approach, the hybrid pedagogical method yielded better learning outcomes in terms of mastery of the basics of radiology [11].

CBL is a student-centered, inquiry-driven teaching method in which learners engage with realistic cases or problem scenarios [12, 13]. Compared with LBL, CBL fosters active participation, collaboration, and lifelong learning skills, making it an ideal pedagogical model for medical and health care education. However, despite its advantages, this teaching approach may fail to fully engage students’ intrinsic motivation for active participation. The efficacy of CBL can be reduced by common obstacles such as uneven participation, which negatively impact both group cohesion and overall learning outcomes. The primary factors contributing to this imbalance are student resistance, particularly among those accustomed to didactic instruction, and the potential for certain learners to experience cognitive overload. These challenges collectively decrease engagement and motivation in the CBL context [14–16].

Compared with clerkship instruction in other medical disciplines, otorhinolaryngology clinical clerkship instruction has unique characteristics, primarily because of the complex anatomy involved, which often intimidate and deter undergraduate students during their learning process. Consequently, the teaching strategy must not only facilitate the transition of students from passive to active learning but also fundamentally stimulate their learning enthusiasm and subjective initiative. Furthermore, the integration of textbook knowledge with clinical imaging, the understanding of surgical indications, and even the formulation of surgical plans all require explicit guidance from and discussion with supervising surgeons. To effectively address these challenges, it is necessary to integrate CBL with other supplementary teaching methods.

Therefore, the IWCL and CBL approaches were combined in this study. In IWCL, the students are involved throughout the entire continuum of patient care—from outpatient consultation to inpatient management and the surgical stage. This continuous, patient-centered learning approach enables the students to systematically follow a single patient’s diagnostic and therapeutic journey, offering several key advantages. First, it fosters holistic clinical reasoning, as students learn to integrate knowledge from multiple disciplines and stages of care rather than viewing each process in isolation. Second, it enhances the continuity of learning and professional responsibility, encouraging students to actively monitor patient progress and appreciate the dynamic evolution of disease and treatment outcomes. Third, by engaging the students in real clinical decision-making and postoperative reflection, it helps them develop stronger practical competence, critical thinking, and problem-solving abilities. Fourth, the approach promotes empathy and patient-centered communication, as continuous interaction enables learners to better understand patients’ psychological needs and experiences. Finally, such longitudinal engagement bridges the gap between theory and practice, cultivating both clinical proficiency and humanistic qualities, which are essential for the development of competent, compassionate physicians. Building on the foundation of CBL, the IC teaching model combines the strengths of both methods, emphasizing case analysis, interactive participation, and continuous clinical engagement.

Our project findings suggest that the IC group was better than the LC group across several key performance indicators. Specifically, students in the IC group exhibited higher proficiency in admission note documentation and anatomical proficiency. Notably, compared with the students in the LC group, those instructed through the IC approach achieved higher theoretical scores, whereas no significant difference was observed between the two groups in speciality physical assessments. In addition, students in the IC group consistently reported higher levels of satisfaction across multiple teaching and learning dimensions than those in the LC group.

However, the implementation of IWCL places high demands on supervising physicians. First, there are a limited number of suitable surgical patients who have been screened in the outpatient clinic and are eligible and willing to be immediately admitted as inpatients to participate in the clinical clerkship. Thus, the attending physician must expend considerable effort in patient screening. Second, owing to issues concerning patient trust and the need for diagnostic and therapeutic accuracy, the entire process must be closely monitored and guided by an experienced physician at the associate chief physician level or above. Finally, this methodology requires supervising physicians to devote a substantial amount of energy to working with different groups of students to familiarize them with the patient’s case, develop the surgical plan, and conduct postoperative review.

Study design considerations and limitations

The study was conducted within a single institutional setting, which may limit the generalizability and transferability of the findings to other medical education contexts with different curricula, teaching cultures, or learner populations. In addition, the study was conducted as a controlled educational intervention in a real-world clinical teaching setting, with group-level allocation rather than individual randomization. Meanwhile, the outcome assessments were performed by an experienced evaluator following a standardized protocol. Nevertheless, the use of a single assessor may have affected measurement reliability. Future studies should incorporate multiple independent evaluators and formally assess inter-rater reliability. Although a computer-generated sequence was used to assign students to one or the other instructional approach, the use of preexisting clerkship groups limited allocation concealment and precluded the blinding of participants and instructors. The absence of a blinded outcome assessment may have introduced assessor bias, particularly in the evaluation of learner performance and engagement. Furthermore, despite efforts to standardize the intervention, potential variations in implementation fidelity across groups may have influenced learner experiences and outcomes. Future research employing more rigorous designs, such as cluster randomized trials with appropriate allocation procedures and blinded outcome assessments, would strengthen the evidence base for the effectiveness of these instructional approaches.

Authors’ contributions

Bing Hu and Hongmiao Ren wrote the main manuscript text .Xiaoqun Su prepared Figs. 1, 2 and 3. Chengcheng Liu prepared supplementary Tables 1-3 and Figs. 4 and 5. All authors reviewed the manuscript.

Funding

The authors disclose receipt of the following financial support for the research, authorship, and publication of this article: the National Natural Science Foundation of China (81700908) and the Natural Science Foundation of Guangdong Province (2016A030310148, 2022A1515011051).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the First Affiliated Hospital of Sun Yat-sen University. All procedures involving human participants were performed in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments. Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.