Effectiveness of a Combined Problem-Based Learning and Flipped Classroom Method in Clinical Skills Training in Ophthalmology | BMC medical training



We selected 75 professional graduates (57 female, 18 male) from the School of Ophthalmology and Optometry, Nanchang University, admitted between September 2018 and 2021. Of the 75 students, 36 were assigned to the PBL group -FC and 39 students in the traditional group. band. There were 29 postgraduate students in first year, 25 postgraduate students in year s and 21 postgraduate students. First-year graduates were freshmen who had no clinical experience, and second- and third-year graduates were seniors who had clinical experience due to their rotational work in relevant clinical departments. Additionally, no participant had previously completed PBL, FC, or PBL combined with FC teaching mode. All students participated in the professional training program in ophthalmology given by the same teacher.

study design

This was a prospective, randomized, controlled study. The students were randomly divided into two groups. The experimental group adopted a combination of PBL and FC teaching methods, and the control group adopted the traditional teaching method. Textbooks, teaching content, lecturers, and total teaching hours were the same in both groups. An overview of the study design flowchart is shown in Fig. 1.

Fig. 1

Teaching schedule

Modules and objectives

The complexity of ocular trauma and the need for individualized treatment require students to have in-depth knowledge of ophthalmic diseases and relevant clinical skills. In addition, the signs and symptoms of eye trauma are easier for students to observe and understand. For this reason, we chose corneal debridement and suturing from the ocular trauma module for this study. This clinical skills course consists of two parts: a theoretical studies course and a practical clinical skills course. We referred to the school’s educational scheme and requirements and formulated educational objectives according to the characteristics of the eye trauma department to help students master corneal debridement and suturing.

PBL with FC group

Formation of the study group

Postgraduate students divided into five groups of six postgraduate students each. A communication platform was set up within the group, group leaders were identified and given enough time to foster interpersonal interactions within the group.

Transfer of knowledge before the course

Professional training content and teaching objectives were sent to students before class in the form of text, PPT, e-books, videos, online learning platforms and other electronic network resources to attract students and improve their understanding ophthalmic knowledge and professional training to optimize their learning time.

To ask questions

Three days before the course, open questions – such as how to treat a corneal laceration involving embedded intraocular tissue, considerations for suturing the cornea in different locations, whether suturing a corneal laceration should be combined with an intraocular injection, how improve refractive suturing, how to treat irregular corneal lacerations or loss of corneal tissue, different ways of shaping the anterior chamber, and their advantages and disadvantages, were discussed and explored independently in groups. The goal was to enable students to obtain an appropriate diagnosis, select an appropriate treatment, and apply what they learned to analyze and solve clinical problems.

Classroom training skills

a) Class discussion: Students in each group summarized and reported to class, presented their responses, and then discussed clinical issues. Finally, the speaker summarized and reviewed all the discussion questions. b) Vocational training: After the discussion, students could practice their skills through animal models.

Traditional group

Classroom training skills

a) Theoretical lessons in class: The lecturer explained the precautions for using the skills and the relevant theoretical knowledge. b) Vocational training: After the theoretical course, the students practiced the operation of skills. They could train skill operations through animal models. If they had questions, they could ask them and the teacher answered.


The students reviewed the course and thought about the relevant questions (the same ones discussed in the PBL-FC group) and gave written answers within a week. The teacher would provide answers to each question and help students solve the problem if they asked for help.

Evaluation of teaching effectiveness

Subjective assessment

All students self-assessed their ability to learn independently before and after class using the Learning Ability Questionnaire (LAQ) [13]. Students were asked to choose the response that best described their actual situation and were told that the questionnaire had no connection to their academic performance. In addition, all students completed a feedback questionnaire three days after the course. The questionnaire was adapted from Ramsden’s Curriculum Experience Questionnaire (CEQ) and Biggs’ Research Process Questionnaire [14]. The questionnaire used a standard five-point Likert scale, with positive item agreement levels ranging from 5 (strongly agree) to 1 (strongly disagree) and negative item agreement levels ranging from 1 ( strongly agree) to 5 (strongly disagree). Higher scores on both the LAQ and the feedback questionnaire mean better results.

Objective assessment

Theoretical exams

Three days before the course, all students took a pre-course theoretical exam on eye trauma, followed by a post-test after three days of the course. All objective assessments were conducted collaboratively by clinicians and professional education instructors and reviewed by three experts holding a senior assistant designation or above, with a total score of 100 to assess basic understanding of students about the disease. In addition, students were asked to indicate the time required for pre-course preparation and post-course review.

Skills assessment

Before the skill operation assessment, we standardized each operation process and key points, assigned step and point values, and created the assessment form. He was tested three days after the course. We used the Delphi method to complete three sets of expert questions, reviewed and modified the evaluation form, and finally completed it with a total score of 100. The same teacher was scored according to an evaluation form standardized.

statistical analyzes

The data was entered by two people and checked twice. All statistical analyzes were performed using SPSS (version 23.0, Chicago, IL, USA). The measurement data was first tested to determine whether it conforms to the normal distribution, using the mean ± standard deviation or the median (interquartile range). If consistent with the normal distribution, the independent sample t-test was used for comparison between groups; otherwise, the Mann-Whitney U test was used. The α was set at 0.05, and P-values ​​less than 0.05 were considered statistically significant.


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