Competency-Based Medical Education in Preclinical Training: Reframing Transformations in the Post-Pandemic Era — a Systematic Review

Competency-Based Medical Education in Preclinical Training: Reframing Transformations in the Post-Pandemic Era — a Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Competency-Based Medical Education in Preclinical Training: Reframing Transformations in the Post-Pandemic Era — a Systematic Review Morris Gellisch, Juliane Cramer, Yasmin Bayer, Micha Gundelfinger, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6811456/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Competency-Based Medical Education (CBME) has evolved over decades, prioritizing real-world proficiency over traditional, time-based training. While its application has been well established in clinical education, its integration into the preclinical phase is gaining traction, particularly in response to the challenges highlighted by the COVID-19 pandemic. The shift to digital learning formats disrupted hands-on training, peer interaction, and professional identity formation, underscoring the need for structured competency development early in medical education. This systematic review explores how CBME principles are being incorporated into preclinical education, examining diverse teaching methodologies and their role in bridging the gap between foundational knowledge and clinical application. By employing a structured analysis of competency frameworks, we identified recurring patterns in the alignment of educational strategies with targeted learning outcomes. Our findings reveal that certain competency domains frequently co-occur in more elaborate instructional designs, suggesting inherent synergies that may support both knowledge retention and transferability. While these developments mark progress, the field still lacks a comprehensive, empirically validated framework for CBME implementation in preclinical education. More systematic research is needed to refine best practices, optimize instructional approaches, and harness the potential synergy between competencies. Strengthening the evidence base will be essential for guiding the future integration of CBME, ensuring that competency-driven education begins early and effectively prepares students for the evolving demands of medical practice. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Medical education has seen countless trends come and go, each promising to revolutionize how we train future physicians. Some fade into obscurity, others leave a lasting mark — but Competency-Based Medical Education (CBME) stands apart. Unlike many short-lived innovations, it has been debated, refined, and reimagined for decades, yet it remains a cornerstone of medical education today. And while entire volumes have been written attempting to define what "competency" truly means (J. R. Frank et al., 2010 ; Leung, 2002 ; ten Cate, 2017 ), perhaps it all boils down to this: CBME isn’t just about logging hours in lecture halls or completing required rotations. It’s about ensuring that medical students don’t just go through the motions of training (Harden, 2007 ; Voorhees, 2001 ) but actually emerge as competent, capable physicians — ready for the unpredictable realities of patient care. Recognizing this need, several frameworks have been introduced to define and operationalize competency domains in medical education (Epstein, 2002 ). The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project (1998) placed a strong emphasis on structuring medical training around six core competency domains — patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice — shifting the focus from time-based training to assessable, outcome-driven education (Swing, 2007 ). These efforts marked a shift away from time-based training models, reinforcing the idea that competence is defined by observable, real-world proficiency rather than the mere completion of curricular milestones. A major step toward structuring these competencies was the CanMEDS initiative, which identified seven key physician roles beyond medical expertise, including communication, collaboration, and leadership (J. Frank, 2005 ; J. R. Frank & Danoff, 2007 ). More than just a theoretical construct, CanMEDS provided a practical framework for integrating these competencies into curricula and assessments (“CanMEDS 2000: Extract from the CanMEDS 2000 Project Societal Needs Working Group Report,” 2000; J. Frank, 2005 ; J. R. Frank & Danoff, 2007 ). However, its implementation highlighted a fundamental challenge: competency is not a fixed set of skills but must be adaptable to context and individual circumstances. Successfully integrating this into curricula is far from trivial, as it requires bridging the gap between theoretical competency frameworks and real-world clinical practice, ensuring that learners are not only assessed on abstract competencies but also on their ability to apply them in complex, dynamic environments (Carraccio et al., 2002 ; ten Cate & Scheele, 2007 ). To operationalize this adaptability, the concept of Entrustable Professional Activities (EPAs) was introduced (ten Cate, 2005 ). While CBME defines competency domains, EPAs translate these into real-world tasks that learners must perform independently before being deemed ready for clinical practice. By linking competence to observable professional activities, EPAs ensure that competency-based education is not merely theoretical but embedded in workplace-based assessment and responsibility (Ten Cate, 2013 ). This need for a situational and context-sensitive approach to medical education was already recognized by McGaghie et al. ( 1978 ), who argued that the goal of a competency-based program is not to produce a universally standardized physician but rather one who can practice medicine at a defined level of proficiency, tailored to local needs and conditions (McGaghie et al., 1978 ). This reinforces the necessity of contextualized competency development, ensuring that medical training prepares learners not only to meet global standards but also to navigate the specific challenges of their future professional environments (Swing, 2010 ). Yet, while CBME has provided a structured approach to defining and assessing medical competencies, the COVID-19 pandemic starkly underscored what cannot be easily standardized, virtualized, or assessed through written examinations alone. As medical education rapidly shifted to remote formats (Nikas et al., 2022 ; Wilhelm et al., 2022 ), relevant elements of physician training — hands-on procedural skills, real-time clinical decision-making, professional identity formation, and the social and communication skills that make a good physician — were pushed to the periphery (Rehman et al., 2024 ; Saad et al., 2023 ; Sharma & Bhaskar, 2020 ). Clinical placements were reduced, peer-to-peer learning diminished, and structured opportunities for developing teamwork, communication, and adaptability — competencies central to patient-centered care — became increasingly scarce (Wang et al., 2024 ). Professional Identity Formation (Jarvis-Selinger et al., 2019 ), an important aspect of early medical training, was equally affected: Beyond acquiring medical knowledge, students develop their professional roles through experiences that were largely disrupted during the pandemic, particularly in the preclinical years (Henderson et al., 2024 ). The COVID-19 pandemic accelerated the adoption of digital learning formats, offering greater flexibility in medical education. However, while online teaching provided logistical advantages, it also came with significant drawbacks, particularly regarding student engagement, peer interaction, and hands-on skill acquisition (Gellisch et al., 2022 , 2023 ; Saad et al., 2023 ; Sharma & Bhaskar, 2020 ; Wanigasooriya et al., 2021 ). Studies have shown that students trained during this period reported decreased confidence in their practical abilities, with procedural competencies — such as venipuncture — being notably affected (Saad et al., 2023 ). Performance assessments revealed significantly lower scores in these areas compared to pre-pandemic cohorts (Saad et al., 2023 ). These findings align with a recently described phenomenon, the Contextual Digital Divide, which highlights that digital education, due to its inherent limitations, cannot fully meet learning needs in contexts requiring direct interaction and hands-on engagement (Gellisch et al., 2025 ). Particularly in skills-based training, digital modalities fail to replicate essential aspects of experiential learning, tutor feedback, and real-time decision-making. These shortcomings are not minor disruptions; they represent a fundamental challenge to the next generation of physicians, who must operate in an increasingly complex healthcare landscape where neither basic knowledge nor technical expertise alone are sufficient. Despite the success of CBME in clinical training, its integration into the preclinical phase remains conceptually and practically challenging. Basic science courses traditionally emphasize knowledge acquisition over demonstrable competencies, and preclinical curricula often lack structured opportunities for contextual learning or workplace-based assessment. Yet, establishing competence early — especially in communication, reasoning, and professional attitudes — is vital to ensure a seamless progression into clinical training. In addition, preclinical medical students faced distinct challenges during the COVID-19 pandemic, including limited access to hands-on learning, reduced peer interaction, and an abrupt transition to remote instruction. These disruptions highlight the need to critically reflect on the lessons learned, ensuring that competency gaps do not persist as medical education continues to evolve in an increasingly digital landscape. To prevent these shortcomings from becoming entrenched in future training models, CBME must be integrated earlier in the curriculum, fostering structured competency development from the outset. To address this gap, our systematic review explores how CBME has been implemented and adapted in preclinical medical education in the post-pandemic era. By consolidating existing initiatives and innovations, we aim to provide a comprehensive foundation upon which the medical education community can collectively build, ensuring that preclinical training aligns with the evolving demands of competency-based learning. Material and Methods 1. Search strategy We conducted a systematic literature search in PubMed (MEDLINE® database; National Institutes of Health, United States National Library of Medicine, Bethesda, MD) on October 10, 2024. The search covered articles published between 2021 and 2024, yielding a total of 134 results. To ensure a comprehensive selection of relevant studies, we used the following search query: ("competency based medical education"[Title/Abstract] OR "CBME"[Title/Abstract] OR "competency-based curriculum"[Title/Abstract] OR "competency-based training"[Title/Abstract] OR "competency framework"[Title/Abstract] OR "competency"[Title/Abstract]) AND ("preclinical"[Title/Abstract] OR "pre-clinical"[Title/Abstract] OR "basic science"[Title/Abstract] OR "early medical education"[Title/Abstract] OR "early stage medical education"[Title/Abstract]). This strategy was designed to capture studies focusing on competency-based medical education (CBME) within the early stages of medical training, ensuring that both broad and specific terminology related to CBME and preclinical education were included. 2. Study selection and inclusion criteria A total of 396 records were initially identified from PubMed. After excluding 254 records published in 2020 or earlier, 142 remained for screening. Each record was evaluated based on predefined inclusion criteria to ensure relevance and methodological rigor. Studies were included if they focused on human participants within a healthy study population, were peer-reviewed empirical investigations published in academic open-access journals and directly examined Competency-Based Medical Education (CBME) within preclinical training. Additionally, only studies that assessed changes in competency development were considered for inclusion. This review focused on how CBME evolved in preclinical medical education between 2021 and 2024, particularly in response to the challenges brought about by the COVID-19 pandemic. Lockdowns and restrictions accelerated the adoption of digital learning, prompting educators to develop new approaches that balanced remote instruction with hands-on skill acquisition. Many studies examined how these adaptations influenced students’ competencies, often comparing different cohorts exposed to varying learning conditions during the pandemic. To identify relevant studies, we first screened titles and abstracts, excluding articles that did not meet the inclusion criteria, such as those focusing on veterinary medicine, clinical research, or general curriculum evaluations. This initial screening led to the removal of 97 records, leaving 45 studies for further review. After a more detailed assessment, an additional 25 records were excluded for lacking a clear preclinical focus or an explicit evaluation of competency development. Ultimately, 20 studies met all criteria and were included in the final analysis. A careful and unbiased selection process was ensured through an independent review of the studies, followed by the compilation of a list of relevant articles. Any disagreements regarding inclusion were addressed through discussion and full-text review until a consensus was reached. The study selection process is illustrated in Fig. 1 . 3. Data extraction A standardized data extraction framework was employed to systematically compile relevant information from the final set of included studies. The extracted variables included authors and year, providing citation details to contextualize the publication, as well as the country of study, reflecting regional variations in CBME implementation. Information on the study population was recorded, specifying the academic level and training stage of participants to ensure relevance to preclinical education. Additionally, the research purpose of each study was documented to highlight its primary focus within the broader CBME framework. The study design was categorized based on methodological approaches, including interventional studies, psychometric validation, and comparative analyses. The educational format was detailed, capturing CBME-aligned instructional methods such as simulation-based learning, case-based learning, or blended learning models. Extracted data also included competency and growth domains, specifying which competencies were targeted, such as clinical reasoning, communication skills, or procedural proficiency. To assess outcomes, information on measured parameters and questionnaires was collected, including multiple-choice quizzes, structured observations, and student feedback surveys. Furthermore, each study’s future research recommendations and key results, including statistical findings where applicable, were summarized to provide insights into the effectiveness of CBME adaptations in preclinical education. The final dataset was synthesized to identify overarching trends in CBME implementation, facilitating a structured comparative analysis of how competency-based principles have been integrated into preclinical medical training (Table 1 ). Table 1 Authors (Year) Country Study population Research purpose Study design Education format Competency and growth Measured parameters, questionnaires Future research Results (Burney et al., 2024 ) USA 90 preclinical medical students To assess the effectiveness of a game-based intervention (Patient Communication Challenge) in improving jargon-free patient communication Interventional study with post-workshop surveys Game-based learning, interactive workshops, role-playing, flipped classroom approach Patient-centered communication, health literacy, use of plain language in clinical settings Post-workshop self-efficacy survey (5-point Likert scale), free-text qualitative feedback To assess long-term skill retention, integrate game into clinical training, expand to other health professions 91% reported improved proficiency in avoiding jargon, 94% would recommend the workshop, 100% would play again (Chen et al., 2022 ) Taiwan 140 third-year medical students at Taipei Medical University, Taiwan To investigate whether ultrasound training enhances anatomy learning outcomes Crossover study with pre- and post-course assessments Parallel Ultrasound Hands-on (PUSH) course; seven 40-min lectures, two 120-min hands-on practical workshops, small-group learning (1:4 tutor-to-student ratio) Anatomical knowledge retention, three-dimensional spatial awareness, sonoanatomy skills, self-efficacy in cognitive, affective, and psychomotor learning domains Written midterm and final exam scores (MCQs), laboratory exam on cadavers, self-efficacy questionnaire (5-point Likert scale) To assess long-term retention of ultrasound-integrated anatomy training, refine assessment alignment between ultrasound and cadaveric anatomy, explore implementation in other institutions Improved midterm written exam scores (7.6% increase, P = 0.014, Cohen’s d = 0.43), no significant improvement in final exam or laboratory test scores, positive student feedback on self-efficacy (Mean = 3.68, SD = 0.56) (Dahmen et al., 2022 ) Germany 263 (SS2019) + 212 (SS 2020) second-semester preclinical medical students at Ulm University, Germany To compare the impact of transitioning from an Inverted Classroom (IC) format to an online-only format on student satisfaction and biochemistry exam performance Observational comparative study across two cohorts (pre-pandemic IC vs. pandemic-driven online teaching) Inverted Classroom (SS2019) with self-learning phases and in-person teamwork, vs. fully online seminar (SS2020) with pre-recorded lectures, self-directed learning, and online synchronous discussion Biochemistry knowledge, protein biosynthesis, medical communication, oral exam preparation, and patient consultation Student satisfaction survey (Likert scale), free-text feedback evaluation, final biochemistry exam scores (MCQ-based assessment) To investigate long-term retention of knowledge in different formats, explore blended learning combinations for optimal results Comparable student satisfaction in both formats, but significantly higher exam scores in the online cohort (18.3 vs. 15.3, p < 0.001) (House et al., 2021 ) USA 167 first-year medical students (and 652 healthcare professionals at the University of Michigan Medical School To evaluate the effectiveness of the Interprofessional Clinical Experience (ICE) course using a multimodal approach Mixed-methods study using student evaluations, preceptor assessments, and competency evaluations Clinical site visits, experiential learning, reflective assignments, online discussions, and preceptor feedback Interprofessional collaboration, communication, teamwork, professionalism, leadership Readiness for Interprofessional Learning Scale (RIPLS), multiple-choice knowledge quiz, preceptor competency assessments, student course evaluations Longitudinal tracking of students into clinical years to assess the lasting impact of ICE training Significant improvements in student attitudes toward interprofessional collaboration, increased knowledge of healthcare roles, and strong competency ratings from preceptors (Khan et al., 2021 ) India 103 first-year medical students (and 6 faculty members at a medical college in North India) To rapidly transition preclinical practical classes to an online format during COVID-19 and assess the feasibility of the Demonstrate-Engage-Assess Practical Teaching (DEAPP) framework Mixed-method study (quantitative feedback and qualitative interviews) Online teaching using recorded/ live videos, gamified quizzes, MCQs, interactive polling, small group discussions Practical skills in Anatomy, Physiology and Biochemistry; critical thinking; self-assessment Student satisfaction survey (Likert scale), faculty interviews, self-assessment through quizzes and MCQs Need for blended learning (combination of online and offline); improvements in interaction and experiential learning DEAPP framework was effective, engaging, and resource-efficient, but lacked hands-on experience; students favoured blended learning over fully online formats (McMains et al., 2023 ) USA 22 first- and second-year healthcare students at East Carolina University Brody School of Medicine To assess if students learn, retain, and enjoy emergency medicine (EM)-focused simulation-based learning (SBL) Interventional study with pre-, post-, and delayed retention assessments Four SBL events: suturing, medical stabilization (MedEvac), mass casualty triage, point-of-care ultrasound (POCUS); pre-event lectures, hands-on simulation, knowledge quizzes Clinical knowledge retention, procedural skills (suturing, triage, airway management, ultrasound use), emergency medicine decision-making Pre- and post-event quizzes (MCQs), retention assessments at 20–100 days, participant satisfaction survey (5-point Likert scale) To investigate long-term retention, assess skill transfer to clinical settings, refine SBL curriculum for broader medical education integration Significant improvement in knowledge scores post-event (p ≤ 0.05); no significant decline in knowledge retention over time; high student satisfaction with SBL format (Michael et al., 2021 ) USA 229 preclinical medical students (and 25 health profession students) To develop and validate an assessment instrument for structured patient handovers Psychometric validation study with confirmatory factor analysis (CFA) Virtual course using Microsoft Teams, simulation-based patient handover training, pre-reading materials, instructional videos Structured communication, closed-loop communication, clarifying questions in patient handovers Behavioral assessment instrument with 7 items, inter-rater reliability (Krippendorff’s alpha = 0.6245), confirmatory factor analysis To expand instrument validation, test across different health professions, assess long-term retention of handover skills, adapt for different structured communication frameworks Established reliability and preliminary construct validity for handover competency assessment instrument (Nayak et al., 2023 ) India 250 first-year MBBS (Bachelor of Medicine and Bachelor of Surgery) students at Kasturba Medical College, Manipal Academy of Higher Education, India To evaluate the impact of simulated patient (SP) videos on student learning and satisfaction in an integrated competency-based medical curriculum Interventional study comparing paper-based clinical cases with SP video-supported cases Integrated teaching using clinical linker cases, SP videos, paper-based cases, interactive discussions, and structured teaching modules Clinical reasoning, patient communication, application of basic science concepts in clinical settings, teamwork in healthcare Student feedback surveys (Likert scale), focus group discussions (FGDs), performance on MCQ-based integrated assessments To investigate long-term impact of SP videos on knowledge retention, assess effect on clinical skill development, expand study to clinical years 80% preferred SP videos for understanding clinical relevance, significantly higher test scores in SP video group (p < 0.001), positive student feedback on engagement and integration (Nguyen et al., 2021 ) USA 121 second-year medical students at Florida International University Herbert Wertheim College of Medicine To enhance medical students’ understanding of osteoporosis through an interactive case-based learning session Interventional study with pre- and post-assessment Small-group case-based learning (CBL), roundtable discussion, integration of foundational sciences and clinical disciplines, remote learning adaptation (Zoom, Google, Docs) Clinical reasoning, osteoporosis diagnosis and management, evidence-based medicine, musculoskeletal physical exam skills Final exam multiple-choice questions (MCQs), post-session student satisfaction survey Potential improvements include incorporating a baseline readiness assessment and refining osteoporosis-related exam questions for better discrimination High student performance on session-related exam questions (84%, increasing to 93% after removing an outlier), 94% student satisfaction with session effectiveness (Oh et al., 2024 ) USA 382 dental students (Classes of 2021, 2022, 2023) at the University of Maryland School of Dentistry To evaluate the impact of curriculum modifications on periodontal instrumentation skills development during the COVID-19 pandemic Observational study with longitudinal assessment of practical and competency exam scores Onsite simulation-based learning (SBL) for Classes of 2021 and 2022, remote SBL for Class of 2023, modified clinical training with restricted patient care Periodontal instrumentation, clinical manual skills, dental assessment techniques First- and second-year practical exams, fourth-year patient-based scaling competency exam, clinic points, multiple linear regression analysis To investigate long-term retention of skills, assess digital vs. in-person learning models, optimize preclinical to clinical transition No significant difference in fourth-year competency exam scores across classes, clinical experience (clinic points) was the strongest predictor of skill development (Olson et al., 2024 ) USA 186 first-year medical students at Case Western Reserve University School of Medicine To evaluate obesity education gaps, introduce a new curriculum, and assess its impact on attitudes and knowledge Curriculum audit, interventional study with pre- and post-surveys, comparison with historical cohort Team-based learning (TBL) on obesity pathogenesis and treatment, standardized patient counselling workshops, revised lectures, integrated obesity-related case discussions Obesity-related medical knowledge, clinical reasoning, patient counselling, shared decision-making, motivational interviewing Likert-scale survey on obesity attitudes and knowledge (pre/post), comparison with historical control group To improve obesity curriculum in clinical years, enhance knowledge on body composition and physical exams, verify full implementation of recommendations Improved obesity knowledge in 14/15 areas (p < 0.001), reduced bias towards obesity as a personal choice, increased self-efficacy in obesity counselling (Roberts et al., 2024 ) USA Study A: 313 preclinical students, Study B: 62 clinical students, University of Oklahoma To assess self-directed learning (SDL) readiness and development over time Longitudinal study with surveys (SDLRS) and qualitative analysis Self-directed learning activities, preclinical and clinical experiences Self-directed learning, critical self-evaluation, self-determination, learning efficacy Self-Directed Learning Readiness Scale (SDLRS), thematic qualitative analysis To expand qualitative analysis, evaluate curriculum changes to enhance SDL development Increased self-determination scores in preclinical years, qualitative insights into SDL development (Robertson et al., 2024 ) USA 354 second-year medical students To evaluate the impact of an online case-based musculoskeletal module on student learning and performance Interventional study with case-based learning and quiz performance analysis Online asynchronous learning, case-based clinical scenarios, multiple-choice quizzes, pre-recorded mini-lectures Musculoskeletal anatomy, clinical reasoning, diagnostic skills, orthopedic knowledge Module completion rates, quiz scores, course exam performance (NBME subject exam), student perception survey (Likert scale) To expand to other institutions, assess long-term retention, integrate clinical experiences Higher course and NBME exam scores for students completing quizzes (p < 0.001); high module engagement (73% completion rate) (K. A. Rowe et al., 2024 ) USA 135 second-year medical students at Harvard Medical School To evaluate a workshop designed to teach preclinical students how to conduct routine code status discussions (CSDs) Mixed-methods study with pre- and post-surveys (quantitative) and thematic analysis (qualitative) Interactive workshop using Kern’s Six Steps of Curriculum Design, flipped-classroom approach, role-play simulations, small-group discussions, debriefing Communication in end-of-life care, shared decision-making, patient-centred discussions, professional role in advance care planning Pre- and post-session self-efficacy assessment (Likert scale), ability to list six code status options, qualitative thematic analysis of concerns and reflections To assess student performance in real clinical settings, refine the workshop structure, expand study to other institutions, develop longitudinal training for code status discussions Increased knowledge of code status options (p < 0.01), higher confidence in conducting discussions (19% → 64%), key concerns: knowledge gaps, fear of upsetting patients (Sangam et al., 2021 ) India 200 first-year MBBS students at NRI Medical College and General Hospital, Guntur, India To evaluate the effectiveness of case-based learning (CBL) in anatomy education compared to traditional lectures Interventional crossover study with pre-test, post-test and retention test assessments Case-based learning (CBL), small group discussions (5 groups of 20 students), tutor-facilitated sessions, access to reference materials and internet resources Clinical reasoning, anatomical knowledge retention, self-directed learning, problem-solving skills Pre-session MCQ test, post-session MCQ test, retention test (4 weeks later), statistical analysis using t-tests and Chi-square To expand the study to multiple institutions, assessing long-term behavioral changes, refining CBL implementation strategies Higher post-session test scores and knowledge retention in CBL group compared to lecture group, statistically significant improvement in learning outcomes (Schneider et al., 2022 ) Germany 155 second-semester medical students at Ulm University, Germany To evaluate the impact of professional actors (standardized patients) vs. peers in communication training within a biochemistry course Randomized controlled trial (RCT) comparing two intervention groups Competency-based inverted classroom setting, role-playing physician-parent consultation, use of standardized patients (SPs) vs. peers Communication skills, patient-centred explanations, application of biochemistry knowledge in clinical interactions, CanMEDS roles (Scholar, Communicator, Professional, Medical Expert) Self-perceived competency in CanMEDS roles (9-point Likert scale), student evaluation of role-play realism (6-point Likert scale), summative biochemistry MCQ exam To incorporate objective communication assessments, explore impact on long-term clinical performance, refine SP training strategies Both SP and peer role-play groups improved self-perceived competencies, SP group showed significantly higher gains in Scholar and Professional roles, no difference in biochemistry exam performance (Seif et al., 2021 ) Egypt 110 second-year medical students at Ain Shams University, Egypt To introduce early clinical exposure (ECE) in ECG interpretation using a six-step approach and assess its impact on knowledge and skills Interventional study with pre- and post-assessments Blended learning, hands-on ECG training, integrated lectures, online forums, cardiology ward visits, case-based discussions ECG interpretation, clinical reasoning, diagnostic skills, critical thinking Multiple-choice questions (MCQs), Objective Structured Practical Examination (OSPE), student feedback questionnaire, focus group discussions Need for more practice opportunities, integration of additional digital resources, potential inclusion of gaming platforms for ECG learning Significant improvement in ECG interpretation skills, higher post-test scores, positive learner engagement, enhanced self-confidence and motivation (Syed Abd Halim et al., 2023 ) Malaysia 30 final-year medical students from four public universities in Malaysia To explore how preclinical anatomy education influenced students’ clinical training and competency in clinical practice Qualitative phenomenology study using focus group discussions (FGD) Problem-Based Learning (PBL), cadaveric specimens, anatomy models, didactic lectures, interactive multimedia, and virtual reality applications Anatomy knowledge, clinical reasoning, procedural skills (e.g., venous cannulation, catheterization, surface anatomy application), integration of anatomy with clinical diagnosis Thematic analysis of focus group discussions, student perceptions on anatomy knowledge application, challenges in anatomy learning To investigate effectiveness of multimodal anatomy teaching, assess long-term knowledge retention, improve clinical integration of anatomy education Identified six key themes: preclinical anatomy learning experience, anatomy content and teaching, anatomy-related competencies, importance of anatomy knowledge in clinical practice, need for early exposure to applied clinical anatomy, recommendations for improving anatomy teaching (Venkatesh et al., 2024 ) India 150 first-year medical students at Trichy SRM Medical College, India To assess the effectiveness of the "keywords recall" technique as a formative assessment tool and its correlation with summative performance Cross-sectional analytical study with multiple assessment methods (MCQs, keyword recall, summative assessments) Traditional preclinical lectures, formative assessments using MCQs and keyword recall Knowledge retention, formative assessment strategies, test-enhanced learning Formative assessment scores (MCQs, keyword recall), summative assessment scores, Pearson correlation analysis To expand sample size, test long-term retention, refine keyword recall as an educational intervention Keyword recall scores were higher than MCQ-based formative assessments (p < 0.001); stronger correlation between keyword recall and summative assessments (r = 0.35) (Zargaran et al., 2022 ) UK 50 pre-clinical and clinical medical students at a higher education institution in the United Kingdom To evaluate the efficacy of high-fidelity simulation training in emergency trauma medicine for undergraduate students One-group pretest-post-test research design Consultant-led lecture, small-group hands-on simulations (chest drain insertion, transoesophageal echocardiogram, splinting), and a simulated major trauma incident Emergency medicine procedures, trauma triage, airway management, surgical interventions, teamwork under stress Pre- and post-training knowledge tests, self-confidence assessment (5-point Likert scale), retention test at six weeks To investigate long-term retention of emergency medicine competencies, refine simulation scenarios for greater realism, explore integration into standard curricula 35.8% immediate post-simulation improvement in knowledge, 22.4% improvement at six weeks, 24% increase in confidence in emergency settings (p < 0.001) Results 1. Study selection and general characteristics Out of the 142 records screened, 20 fully met the inclusion criteria and were included in this review. These studies were consistently published throughout the selected time frame with six studies in 2021, four in 2022, four in 2023, and six in 2024. The included studies were analyzed based on their integration of a clinical context within CBME. The results showed that more than half of the studies (n = 12, 60%) incorporated a clinical perspective, whereas the remaining 40% (n = 8) focused exclusively on preclinical education without direct clinical application (Fig. 2 A). An analysis of the geographic distribution revealed that the majority of studies were conducted in the United States, which accounted for half of all included studies (n = 10, 50%). Other countries contributing to CBME research in preclinical education included India (20%, n = 4), Germany (10%, n = 2), as well as Egypt, Malaysia, Taiwan, and the United Kingdom, each represented by a single study (5%, n = 1) (Fig. 2 B). 2. Study populations and participants characteristics To understand the target groups of CBME research, the included studies were categorized based on the educational level of participants. Additionally, the total number of participants in each study was recorded to assess the scale of the investigations. The majority of studies (n = 8) focused on first-year medical students, while four studies examined second-year medical students. The remaining studies either investigated a combination of first- and second-year students, other preclinical students, or both preclinical and clinical medical students (Fig. 3 ). 2. Didactic and methodological approaches The didactic focus and methodological approaches of the 20 selected studies were analyzed and categorized into three groups: 13 studies (65%) introduced a new face-to-face method, 4 studies (20%) evaluated an existing method, and 3 studies (15%) developed a new online tool. The findings indicate that the majority of studies emphasized the development and assessment of in-person teaching methods, underscoring the role of personal interaction in CBME (Fig. 4 A). The study designs of the included articles varied considerably. The most common approach was a pre-post study design (n = 12; 60%), followed by quasi-experimental designs (n = 3; 15%) and observational studies (n = 2; 10%). Additionally, two qualitative retrospective studies (10%) and one randomized controlled trial (5%) were included (Fig. 4 B). 4. Preclinical disciplines and integration of clinical competencies While the studies primarily focused on preclinical students, half of them incorporated clinical aspects within their competency-based approaches, reflecting an effort to integrate foundational medical knowledge with its practical application. To further examine the specific preclinical disciplines addressed in CBME studies, we analyzed 24 references to subject areas across the included articles, providing insights into the scope and emphasis of competency-based approaches within preclinical education. The results showed that six studies (25%) integrated Anatomy, emphasizing its role in developing spatial understanding of human structures and clinical correlations, particularly in surgical and radiological contexts. Four studies (16.7%) included Biochemistry, often in relation to metabolic pathways and molecular mechanisms relevant to clinical diagnostics and pharmacology. Three studies (12.5%) examined Physiology, highlighting its foundational role in understanding normal and pathological bodily functions, which is relevant for fields such as internal medicine and anaesthesiology. One study (4.17%) addressed other preclinical elements, though without a predominant thematic focus. Only one study (4.17%) explicitly combined both preclinical and clinical competencies, demonstrating an integrated approach where students applied foundational biomedical knowledge to clinical scenarios, such as differential diagnosis or patient case discussions (Fig. 5 ). 5. Competencies addressed in CBME studies To provide a structured overview of the competencies targeted in CBME research, a heatmap (Fig. 6 ) was generated. The y-axis lists the included studies based on the first author’s name, while the x-axis categorizes the competencies addressed. These competencies include PRC (Professional competency), CKS (Clinical knowledge and skills), PKS (Preclinical knowledge and skills), PLS (Practical laboratory skills), COS (Communication skills), TEA (Teamwork), LST (Learning strategies), and TRA (Transfer of knowledge/ implementation of preclinical knowledge in clinical practice). The color scheme indicates the extent to which each study incorporated a given competency: green represents a primary focus, orange a secondary role, and red indicates that the competency was not considered. The data reveal substantial variation in competency emphasis across studies. While clinical knowledge and teamwork frequently played a central role (green marking), preclinical knowledge and practical laboratory skills were often assigned as secondary role (orange) or omitted altogether (red). This suggests that there is no universal focus on specific competencies in CBME research, but rather a diverse range of methodological approaches. 6. Teaching formats in CBME studies A second heatmap (Fig. 7 ) was created to visualize the distribution of teaching formats in CBME. The y-axis lists the analyzed studies, while the x-axis represents the teaching methods investigated, including BLL (Blended learning), CBL (Case-based learning), LTO (Learning through observation), LWS (Lecture combined with workshop/simulation), and SDL (Self-directed learning). The color coding follows the same scheme: green indicates primary focus, orange represents a secondary role, and red denotes that the format was not considered. The analysis revealed a heterogeneous distribution of teaching formats across CBME studies. Some studies strongly emphasized blended learning or case-based learning (green marking), whereas others mentioned them only as supplementary aspects (orange marking) or omitted them entirely (red marking). Discussion Our analysis confirms that CBME is increasingly finding its way into preclinical education in the post-pandemic era. Across different countries and disciplines, medical educators are actively integrating competency-based approaches to bridge the gap between foundational knowledge and real-world application. While CBME has traditionally been emphasized in clinical training, our findings highlight a growing recognition that competency development should begin earlier in the curriculum — a shift that is reflected in the diverse educational strategies being explored worldwide. Notably, our analysis reveals that the integration of CBME into preclinical education extends beyond theoretical instruction, incorporating competencies in anatomy, physiology, and biochemistry alongside clinical skills, strengthening a more interconnected and applied learning experience. Yet, despite this clear momentum, its implementation remains anything but uniform. Studies vary not only in the teaching methods they employ but also in how these methods are aligned with specific competencies. One interesting pattern emerging from our analysis is the remarkable diversity of integrated teaching formats in CBME studies. Rather than relying on singular instructional approaches, the majority of studies employed multiple methods, suggesting a deliberate effort to balance structured guidance with student autonomy (Liu & Sullivan, 2021 ; Lu et al., 2023 ; Ricotta et al., 2022 ). The patterns observed in the heatmap suggest that case-based learning (CBL) and self-directed learning (SDL) are frequently implemented together, reflecting a pedagogical strategy that strengthens independent problem-solving while ensuring students engage with clinical reasoning in a structured manner. This observation aligns with existing literature, which has demonstrated that the combination of CBL and SDL enhances student learning outcomes while promoting deeper understanding through active engagement with case materials (Tadadaj et al., 2022 ). Similarly, blended learning (BLL) and lecture-workshop simulations (LWS) often appear in combination, indicating a trend toward integrating digital content with hands-on, interactive components. However, research in this field indicates that high-quality evidence on blended learning in clinical education remains limited (M. Rowe et al., 2012 ). Existing studies offer only preliminary support for its effectiveness in enhancing clinical competencies, underscoring the need for more robust, context-sensitive evaluations that account for variations in implementation, learner engagement, and institutional resources before widespread adoption in competency-based medical education (Jebraeily et al., 2020 ; M. Rowe et al., 2012 ). The growing call from the medical education community to integrate CBME into preclinical training comes with the imperative that this transition must be accompanied by innovative teaching designs that move beyond traditional formats, ensuring a more effective and competency-driven learning experience (Joshi, 2024 ). Our findings suggest that this shift is partly underway, as many studies employ a diverse combination of teaching methodologies (Chen et al., 2022 ; Dahmen et al., 2022 ; House et al., 2021 ; Nguyen et al., 2021 ; Olson et al., 2024 ; Roberts et al., 2024 ; Sangam et al., 2021 ; Schneider et al., 2022 ; Seif et al., 2021 ; Syed Abd Halim et al., 2023 ; Venkatesh et al., 2024 ). This trend reflects a promising movement toward aligning preclinical education with CBME principles, ensuring that knowledge acquisition is dynamic, context-dependent, and applied across multiple learning modalities. Rather than prescribing a single best-practice model, these studies suggest that the strength of CBME lies in its adaptability, allowing educators to tailor learning experiences that bridge theoretical knowledge, clinical reasoning, and practical application. A deeper analysis of our findings reveals distinct patterns in how competencies are addressed within CBME studies. Examining the competency heatmap, it becomes evident that certain competencies frequently appear together, suggesting inherent links in their development and instructional emphasis. This clustering of competencies indicates that competency-based training does not occur in isolation; rather, skills such as communication, teamwork, and professional competency are often cultivated alongside knowledge acquisition and practical skill development. Our analysis reveals that teamwork (TEA) and communication skills (COS) frequently co-occur in competency-based medical education (CBME), highlighting a close relationship between these two competencies. This alignment is consistent with existing research in medical education, which underscores effective communication as a fundamental element of successful teamwork in clinical practice (Borowczyk et al., 2023 ; Lee & Doran, 2017 ; Lerner et al., 2009 ). Given the increasing reliance on interdisciplinary teams in healthcare, the ability to convey information accurately and efficiently is essential — not only to facilitate seamless collaboration but also to enhance patient safety (Chakraborti et al., 2008 ). This association is further reinforced by guidelines from the Institute of Medicine (IOM) and the Accreditation Council for Graduate Medical Education (ACGME), which recognize team-based healthcare as dependent on a shared foundation of knowledge, skills, and attitudes (KSAs), with communication playing a critical role (Baker et al., 2005 ). Empirical studies suggest that well-structured communication within teams leads to fewer mistakes, enhances error recovery, and ultimately contributes to better patient care (Salas et al., 2005 ; Singh et al., 2008 ; Volpe et al., 1996 ). As a result, medical education frameworks increasingly advocate for training approaches that explicitly integrate communication-focused activities into teamwork exercises, including simulation-based learning and structured role-playing (Elendu et al., 2024 ; Herrera-Aliaga & Estrada, 2022 ; Sawaya et al., 2021 ). Further, our heatmap analysis clearly demonstrates that preclinical knowledge and skills (PKS) and clinical knowledge and skills (CKS) frequently co-occur in CBME curricula. This recurring pattern across diverse studies highlights a deliberate pedagogical approach, emphasizing the structured integration of foundational knowledge into clinical application. This observation raises an important question: Why do these competencies appear together so frequently, and what does this tell us about how medical education is evolving? One possible explanation is that educational designs integrating both preclinical and clinical elements foster stronger knowledge consolidation, ensuring that basic scientific concepts are not just acquired in isolation but actively reinforced, interconnected, and anchored within clinical practice. This contextualized application strengthens memory traces, enhancing retention and facilitating smoother knowledge transfer to real-world medical scenarios. Research on learning and memory indicates that applying knowledge across various contexts promotes deeper encoding and enhances long-term retention, surpassing the effects of passive exposure (Nelson-Hurwitz & Tagorda, 2015 ). This perspective aligns with theories emphasizing active engagement and contextual learning as crucial elements in strengthening memory consolidation and knowledge transfer (Ruiz-Martín & Bybee, 2022 ). Moreover, when working memory reaches its capacity — such as during prolonged lectures with continuous information flow — active learning can enhance retention (Dubinsky & Hamid, 2024 ). This provides a neurobiological explanation for why active learning strategies, which intersperse application and interaction, can be more effective in sustaining attention and improving long-term knowledge retention. Teaching designs that integrate PKS and CKS — such as case-based learning (CBL), blended learning (BLL), and structured simulations — help alleviate the cognitive load on working memory by actively engaging learners in applying theoretical concepts. Conclusion This review sheds light on the increasing efforts to integrate CBME principles into preclinical education, a transition that is both promising and methodologically complex. By mapping these developments across diverse educational contexts, we provide a clear picture of how foundational scientific knowledge and clinical competencies are being linked in meaningful ways. Our analysis further highlights the intellectual and didactic effort required to craft teaching strategies that not only impart knowledge but also actively connect it to practical application — a shift that is relevant for implementing truly competency-driven learning environments. One of the most compelling takeaways from this review is the emerging pattern of competency synergies: certain skills, when taught together, appear to reinforce each other naturally, creating potential leverage points for more effective curriculum design. These relationships, while promising, remain underexplored and call for deeper empirical investigation. Understanding how competencies interact could unlock valuable synergies and allow educators to design curricula that maximize learning efficiency while minimizing redundancy. Despite these insights, the body of empirical research on CBME in the preclinical phase remains limited. The studies included in this review provide a valuable direction, but there is a pressing need for empirical educational research to rigorously validate and refine these approaches, ensuring that CBME implementation in the preclinical phase is guided by systematic, evidence-based insights. Moving forward, we encourage the medical education community to expand research efforts in this field, ensuring that CBME is not just an ambition for preclinical education — but a well-supported, evidence-driven reality. Declarations Acknowledgements We extend our sincere gratitude to the Zentrum für Medizinische Lehre der Ruhr-Universität Bochum (ZML) for the opportunity to engage in stimulating discussions on the integration of CBME in preclinical education. In addition, we would like to express our sincere gratitude to Prof. Dr. med. Johannes Loffing for his valuable content-related guidance and expert advice throughout the development of this manuscript. Our deep appreciation also goes to our colleagues at the Studiendekanat der Universitären Medizin Zürich for their valuable collegial exchange, which significantly enriched this work. Furthermore, we affirm that large language models were employed solely under the direct guidance and supervision of the authors, with the exclusive purpose of enhancing the clarity and language of this manuscript. The scientific content, analyses, and interpretations remain entirely the original contributions of the authors. Finally, we acknowledge the support of the Open Access Publication Funds of the Ruhr-Universität Bochum in facilitating the publication of this work. Clinical trial number not applicable References Baker, D. P., Salas, E., King, H., Battles, J., & Barach, P. (2005). The Role of Teamwork in the Professional Education of Physicians: Current Status and Assessment Recommendations. The Joint Commission Journal on Quality and Patient Safety , 31 (4), 185–202. https://doi.org/10.1016/S1553-7250(05)31025-7 Borowczyk, M., Stalmach-Przygoda, A., Doroszewska, A., Libura, M., Chojnacka-Kuraś, M., Małecki, Ł., Kowalski, Z., & Jankowska, A. K. (2023). Developing an effective and comprehensive communication curriculum for undergraduate medical education in Poland – the review and recommendations. BMC Medical Education , 23 (1), 645. https://doi.org/10.1186/s12909-023-04533-5 Burney, E., Arora, M., Gaillard, M., Herzig, M., Lester, L., Park, S., & Coleman, C. (2024). A Game-Based Tool for Reducing Jargon Use by Medical Trainees. MedEdPORTAL . https://doi.org/10.15766/mep_2374-8265.11411 CanMEDS 2000: Extract from the CanMEDS 2000 Project Societal Needs Working Group Report. (2000). Medical Teacher , 22 (6), 549–554. https://doi.org/10.1080/01421590050175505 Carraccio, C., Wolfsthal, S. D., Englander, R., Ferentz, K., & Martin, C. (2002). Shifting Paradigms. Academic Medicine , 77 (5), 361–367. https://doi.org/10.1097/00001888-200205000-00003 Chakraborti, C., Boonyasai, R. T., Wright, S. M., & Kern, D. E. (2008). A Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education. Journal of General Internal Medicine , 23 (6), 846–853. https://doi.org/10.1007/s11606-008-0600-6 Chen, W.-T., Kang, Y.-N., Wang, T.-C., Lin, C.-W., Cheng, C.-Y., Suk, F.-M., Hsu, C.-W., Huang, S.-K., & Huang, W.-C. (2022). Does ultrasound education improve anatomy learning? Effects of the Parallel Ultrasound Hands-on (PUSH) undergraduate medicine course. BMC Medical Education , 22 (1), 207. https://doi.org/10.1186/s12909-022-03255-4 Dahmen, L., Schneider, A., Keis, O., Straßer, P., Kühl, M., & Kühl, S. J. (2022). From the inverted classroom to the online lecture hall: Effects on students’ satisfaction and exam results. Biochemistry and Molecular Biology Education , 50 (5), 483–493. https://doi.org/10.1002/bmb.21650 Dubinsky, J. M., & Hamid, A. A. (2024). The neuroscience of active learning and direct instruction. Neuroscience & Biobehavioral Reviews , 163 , 105737. https://doi.org/10.1016/j.neubiorev.2024.105737 Elendu, C., Amaechi, D. C., Okatta, A. U., Amaechi, E. C., Elendu, T. C., Ezeh, C. P., & Elendu, I. D. (2024). The impact of simulation-based training in medical education: A review. Medicine , 103 (27), e38813. https://doi.org/10.1097/MD.0000000000038813 Epstein, R. M. (2002). Defining and Assessing Professional Competence. JAMA , 287 (2), 226. https://doi.org/10.1001/jama.287.2.226 Frank, J. (2005). The CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care. The Royal College of Physicians and Surgeons of Canada. Frank, J. R., & Danoff, D. (2007). The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Medical Teacher , 29 (7), 642–647. https://doi.org/10.1080/01421590701746983 Frank, J. R., Mungroo, R., Ahmad, Y., Wang, M., De Rossi, S., & Horsley, T. (2010). Toward a definition of competency-based education in medicine: a systematic review of published definitions. Medical Teacher , 32 (8), 631–637. https://doi.org/10.3109/0142159X.2010.500898 Gellisch, M., Bablok, M., Morosan-Puopolo, G., Schäfer, T., & Brand-Saberi, B. (2023). Differences in mental stress parameters of first-year medical students over the three-year course of the ongoing Covid-19 pandemic: A repeated cross-sectional study. Behavioral Sciences . Gellisch, M., Cramer, J., Trenkel, J., Bäker, F., Bablok, M., Morosan-Puopolo, G., Schäfer, T., & Brand-Saberi, B. (2025). Introducing the contextual digital divide: Insights from microscopic anatomy on usage behavior and effectiveness of digital versus face-to-face learning. Anatomical Sciences Education , 1–18. Gellisch, M., Wolf, O. T., Minkley, N., Kirchner, W. H., Brüne, M., & Brand‐Saberi, B. (2022). Decreased sympathetic cardiovascular influences and hormone‐physiological changes in response to Covid‐19‐related adaptations under different learning environments. Anatomical Sciences Education , 15 (5), 811–826. https://doi.org/10.1002/ase.2213 Harden, R. M. (2007). Outcome-Based Education: the future is today. Medical Teacher , 29 (7), 625–629. https://doi.org/10.1080/01421590701729930 Henderson, R. R., Adams, C. A., Thomas, L., Gundersen, E., Zaidi, Z., & Hagen, M. (2024). COVID As a Catalyst: A Qualitative Study Of Professional Identity Formation among U.S. Medical Students During COVID-19. Teaching and Learning in Medicine , 36 (5), 601–612. https://doi.org/10.1080/10401334.2023.2240774 Herrera-Aliaga, E., & Estrada, L. D. (2022). Trends and Innovations of Simulation for Twenty First Century Medical Education. Frontiers in Public Health , 10 . https://doi.org/10.3389/fpubh.2022.619769 House, J. B., Cedarbaum, J., & Santen, S. A. (2021). A Multilevel Model for Evaluating Interprofessional Learning. Medical Science Educator , 31 (2), 349–353. https://doi.org/10.1007/s40670-020-01193-8 Jarvis-Selinger, S., MacNeil, K. A., Costello, G. R. L., Lee, K., & Holmes, C. L. (2019). Understanding Professional Identity Formation in Early Clerkship: A Novel Framework. Academic Medicine , 94 (10), 1574–1580. https://doi.org/10.1097/ACM.0000000000002835 Jebraeily, M., Pirnejad, H., Feizi, A., & Niazkhani, Z. (2020). Evaluation of blended medical education from lecturers’ and students’ viewpoint: a qualitative study in a developing country. BMC Medical Education , 20 (1), 482. https://doi.org/10.1186/s12909-020-02388-8 Joshi, M. K. (2024). Novel teaching–learning and assessment tools to complement competency-based medical education in postgraduate training. Indian Journal of Anaesthesia , 68 (1), 11–16. https://doi.org/10.4103/ija.ija_1175_23 Khan, A. M., Patra, S., Vaney, N., Mehndiratta, M., & Chauhan, R. (2021). Rapid transition to online practical classes in preclinical subjects during COVID-19: Experience from a medical college in North India. Medical Journal Armed Forces India , 77 , S161–S167. https://doi.org/10.1016/j.mjafi.2020.12.030 Lee, C. T.-S., & Doran, D. M. (2017). The Role of Interpersonal Relations in Healthcare Team Communication and Patient Safety. Canadian Journal of Nursing Research , 49 (2), 75–93. https://doi.org/10.1177/0844562117699349 Lerner, S., Magrane, D., & Friedman, E. (2009). Teaching Teamwork in Medical Education. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine , 76 (4), 318–329. https://doi.org/10.1002/msj.20129 Leung, W.-C. (2002). Competency based medical training: review. BMJ (Clinical Research Ed.) , 325 (7366), 693–696. Liu, T.-H., & Sullivan, A. M. (2021). A story half told: a qualitative study of medical students’ self-directed learning in the clinical setting. BMC Medical Education , 21 (1), 494. https://doi.org/10.1186/s12909-021-02913-3 Lu, S. Y., Ren, X. P., Xu, H., & Han, D. (2023). Improving self-directed learning ability of medical students using the blended teaching method: a quasi-experimental study. BMC Medical Education , 23 (1), 616. https://doi.org/10.1186/s12909-023-04565-x McGaghie, W. C., Miller, G. E., Sajid, A. W., & Telder, T. V. (1978). Competency-based curriculum development on medical education: an introduction. Public Health Papers , 68 , 11–91. McMains, J. C., Larkins, M. C., Doherty, A. M., Horiates, J., Alachraf, K., Gordon, J. A., Fletcher, J., & Brewer, K. L. (2023). Knowledge Retention From Emergency Medicine Simulation-Based Learning Curriculum for Pre-clinical Medical Students. Cureus . https://doi.org/10.7759/cureus.41216 Michael, M., Griggs, A. C., Shields, I. H., Sadighi, M., Hernandez, J., Chan, C., McHugh, M., Nichols, B. E., Joshi, K., Testa, D., Raj, S., Preble, R., Lazzara, E. H., & Greilich, P. E. (2021). Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument. BMC Medical Education , 21 (1), 518. https://doi.org/10.1186/s12909-021-02943-x Nayak, K. R., Nayak, V., Punja, D., Badyal, D. K., & Modi, J. N. (2023). Simulated patient videos to supplement integrated teaching in competency-based undergraduate medical curriculum. Advances in Physiology Education , 47 (2), 296–306. https://doi.org/10.1152/advan.00167.2022 Nelson-Hurwitz, D. C., & Tagorda, M. (2015). Developing an undergraduate applied learning experience. Frontiers in Public Health , 3 , 2. https://doi.org/10.3389/fpubh.2015.00002 Nguyen, B., Athauda, G., Kashan, S. B., Weiler, T., & Toonkel, R. L. (2021). Osteoporosis: A Small-Group Case-Based Learning Activity. MedEdPORTAL . https://doi.org/10.15766/mep_2374-8265.11176 Nikas, I. P., Lamnisos, D., Meletiou‐Mavrotheris, M., Themistocleous, S. C., Pieridi, C., Mytilinaios, D. G., Michaelides, C., & Johnson, E. O. (2022). Shift to emergency remote preclinical medical education amidst the Covid‐19 pandemic: A single‐institution study. Anatomical Sciences Education , 15 (1), 27–41. https://doi.org/10.1002/ase.2159 Oh, S., Mishler, O., Syme, S., Jones, D., & Saito, H. (2024). Impact of the modified curricula on periodontal instrumentation skills development during the COVID‐19 pandemic from 2020 to 2023. Journal of Dental Education , 88 (11), 1503–1510. https://doi.org/10.1002/jdd.13632 Olson, A., Watowicz, R., Seeholzer, E., Lyons, K., Butsch, W. S., & Croniger, C. (2024). Preclinical obesity curriculum: audit, implementation, and evaluation. BMC Medical Education , 24 (1), 639. https://doi.org/10.1186/s12909-024-05606-9 Rehman, M., Khalid, F., Sheth, U., Al-Duaij, L., Chow, J., Azim, A., Last, N., Blissett, S., & Sibbald, M. (2024). Quarantining From Professional Identity: How Did COVID-19 Impact Professional Identity Formation in Undergraduate Medical Education? Perspectives on Medical Education , 13 (1). https://doi.org/10.5334/pme.1308 Ricotta, D. N., Richards, J. B., Atkins, K. M., Hayes, M. M., McOwen, K., Soffler, M. I., Tibbles, C. D., Whelan, A. J., & Schwartzstein, R. M. (2022). Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery. Teaching and Learning in Medicine , 34 (5), 530–540. https://doi.org/10.1080/10401334.2021.1938074 Roberts, M., Darden, A., Wiskur, B., & Hill, M. (2024). A Longitudinal Assessment of Self-directed Learning Readiness and Development in Medical Students. Journal of Medical Education and Curricular Development , 11 . https://doi.org/10.1177/23821205241242261 Robertson, K., McNulty, M. A., Natoli, R. M., Stout, J., & Ulrich, G. (2024). Musculoskeletal Clinical Online Cases With a Focus on Anatomy for Preclinical Learners. MedEdPORTAL . https://doi.org/10.15766/mep_2374-8265.11457 Rowe, K. A., Ouchi, K., Kennedy, M., Breu, A., Tolchin, D. W., & Schwartz, A. W. (2024). Preparing Preclinical Medical Students for Routine Code Status Discussions: A Mixed-Methods Study. Journal of Pain and Symptom Management , 67 (2), 138–146. https://doi.org/10.1016/j.jpainsymman.2023.10.017 Rowe, M., Frantz, J., & Bozalek, V. (2012). The role of blended learning in the clinical education of healthcare students: A systematic review. Medical Teacher , 34 (4), e216–e221. https://doi.org/10.3109/0142159X.2012.642831 Ruiz-Martín, H., & Bybee, R. W. (2022). The cognitive principles of learning underlying the 5E Model of Instruction. International Journal of STEM Education , 9 (1), 21. https://doi.org/10.1186/s40594-022-00337-z Saad, S., Richmond, C., King, D., Jones, C., & Malau-Aduli, B. (2023). The impact of pandemic disruptions on clinical skills learning for pre-clinical medical students: implications for future educational designs. BMC Medical Education , 23 (1), 364. https://doi.org/10.1186/s12909-023-04351-9 Salas, E., Sims, D. E., & Burke, C. S. (2005). Is there a “Big Five” in Teamwork? Small Group Research , 36 (5), 555–599. https://doi.org/10.1177/1046496405277134 Sangam, M. R., K, P., G, V., Bokan, R. R., Deka, R., & Kaur, A. (2021). Efficacy of Case-Based Learning in Anatomy. Cureus . https://doi.org/10.7759/cureus.20472 Sawaya, R. D., Mrad, S., Rajha, E., Saleh, R., & Rice, J. (2021). Simulation-based curriculum development: lessons learnt in Global Health education. BMC Medical Education , 21 (1), 33. https://doi.org/10.1186/s12909-020-02430-9 Schneider, A., Messerer, D. A. C., Kühn, V., Horneffer, A., Bugaj, T. J., Nikendei, C., Kühl, M., & Kühl, S. J. (2022). Randomised controlled monocentric trial to compare the impact of using professional actors or peers for communication training in a competency-based inverted biochemistry classroom in preclinical medical education. BMJ Open , 12 (5), e050823. https://doi.org/10.1136/bmjopen-2021-050823 Seif, A. A., Eldamanhoury, H. M., Darahim, K., Boulos, D. N. K., Bahaa, N., A M, C., Velladath, S. U., & Kamath, M. G. (2021). EE-6S: an integrated approach for introducing early clinical exposure in the new Egyptian medical curriculum. Advances in Physiology Education , 45 (1), 109–120. https://doi.org/10.1152/advan.00166.2020 Sharma, D., & Bhaskar, S. (2020). Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic. Frontiers in Public Health , 8 . https://doi.org/10.3389/fpubh.2020.589669 Singh, H., Naik, A. D., Rao, R., & Petersen, L. A. (2008). Reducing diagnostic errors through effective communication: harnessing the power of information technology. Journal of General Internal Medicine , 23 (4), 489–494. https://doi.org/10.1007/s11606-007-0393-z Swing, S. R. (2007). The ACGME outcome project: retrospective and prospective. Medical Teacher , 29 (7), 648–654. https://doi.org/10.1080/01421590701392903 Swing, S. R. (2010). Perspectives on competency-based medical education from the learning sciences. Medical Teacher , 32 (8), 663–668. https://doi.org/10.3109/0142159X.2010.500705 Syed Abd Halim, S. A., Yusoff, M. S. B., Yaman, M. N., Razali, S. A., Tengku Muda, T. F. M., Ramli, R. R., Kadir, F., & Hadie, S. N. H. (2023). Clinical students’ reflections on the preclinical anatomy learning experience. Journal of Taibah University Medical Sciences , 18 (4), 757–770. https://doi.org/10.1016/j.jtumed.2022.12.007 Tadadaj, C., Wannapiroon, P., & Sillabutra, J. (2022). Case-Based Learning in Self-directed Learning Environment using a Digital Platform to Enhance Public Health Students’ Learning Outcome in Graduate Study. TEM Journal , 1653–1659. https://doi.org/10.18421/TEM114-28 ten Cate, O. (2005). Entrustability of professional activities and competency-based training. Medical Education , 39 (12), 1176–1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x Ten Cate, O. (2013). Nuts and bolts of entrustable professional activities. Journal of Graduate Medical Education , 5 (1), 157–158. https://doi.org/10.4300/JGME-D-12-00380.1 ten Cate, O. (2017). Competency-Based Medical Education and its Competency Frameworks (pp. 903–929). https://doi.org/10.1007/978-3-319-41713-4_42 ten Cate, O., & Scheele, F. (2007). Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? Academic Medicine , 82 (6), 542–547. https://doi.org/10.1097/ACM.0b013e31805559c7 Venkatesh, K., Muthukumar, D., Kamala, E., & Muhil, M. (2024). Study of Efficacy of a Novel Formative Assessment Tool: Keywords Recall. Cureus . https://doi.org/10.7759/cureus.69881 Volpe, C. E., Cannon-Bowers, J. A., Salas, E., & Spector, P. E. (1996). The Impact of Cross-Training on Team Functioning: An Empirical Investigation. Human Factors: The Journal of the Human Factors and Ergonomics Society , 38 (1), 87–100. https://doi.org/10.1518/001872096778940741 Voorhees, A. B. (2001). Creating and Implementing Competency‐Based Learning Models. New Directions for Institutional Research , 2001 (110), 83–95. https://doi.org/10.1002/ir.13 Wang, W., Li, G., & Lei, J. (2024). The impact of COVID-19 on medical students. GMS Journal for Medical Education , 41 (1), Doc10. https://doi.org/10.3205/zma001665 Wanigasooriya, K., Beedham, W., Laloo, R., Karri, R. S., Darr, A., Layton, G. R., Logan, P., Tan, Y., Mittapalli, D., Patel, T., Mishra, V. D., Odeh, O., Prakash, S., Elnoamany, S., Peddinti, S. R., Daketsey, E. A., Gadgil, S., Bouhuwaish, A. E. M., Ozair, A., … Ashpak, A. (2021). The perceived impact of the Covid-19 pandemic on medical student education and training – an international survey. BMC Medical Education , 21 (1), 566. https://doi.org/10.1186/s12909-021-02983-3 Wilhelm, J., Mattingly, S., & Gonzalez, V. H. (2022). Perceptions, satisfactions, and performance of undergraduate students during Covid‐19 emergency remote teaching. Anatomical Sciences Education , 15 (1), 42–56. https://doi.org/10.1002/ase.2161 Zargaran, A., Houlden, R., O’Neill, P., Schaffer, S., Chang, V., Kafai Golahmadi, A., Hirniak, J., Turki, M., & Zargaran, D. (2022). Emergency medicine undergraduate simulation training during the COVID-19 pandemic: A course evaluation. Injury , 53 (10), 3191–3194. https://doi.org/10.1016/j.injury.2022.07.003 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6811456","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":469448239,"identity":"0adf31c5-1348-4bca-936b-d24a3efa26c7","order_by":0,"name":"Morris Gellisch","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIie3QMQrCMBSA4RcCulRcM+kJhErBSexVUgq6WGeHDhGhTuJaofdwTQnUxQM4ODh1KqJbhSKm1cXBtqNgfkKm98FLAFSqX43mVxMzDsA7AFpxahCMCmLUI/Am8uYWqyK91Tq+njMYbTBahKl7mux8h0My/04Gh73hWx7Y2yViQotiJzjOKAoOJeQ4xiCXsXUhiTyOT6Y6bnkVhGZgm3I+vDMxIQV5VJEGjPT8x1pM0BdhZW+J5GIeoUQUbxF9X7vQMIhKyN7DKM2GZnu1FLfUFV3SdMJz4n4n74j1sQmvBDKzzpBKpVL9aU/+DlQZ41f78QAAAABJRU5ErkJggg==","orcid":"","institution":"Ruhr-University Bochum","correspondingAuthor":true,"prefix":"","firstName":"Morris","middleName":"","lastName":"Gellisch","suffix":""},{"id":469448240,"identity":"bbbd6cb5-8d9a-4eb6-a155-bf394b8d476a","order_by":1,"name":"Juliane Cramer","email":"","orcid":"","institution":"Ruhr University Bochum","correspondingAuthor":false,"prefix":"","firstName":"Juliane","middleName":"","lastName":"Cramer","suffix":""},{"id":469448241,"identity":"d136b60d-8b26-4420-aa09-b7359f472bd3","order_by":2,"name":"Yasmin Bayer","email":"","orcid":"","institution":"University of Zurich","correspondingAuthor":false,"prefix":"","firstName":"Yasmin","middleName":"","lastName":"Bayer","suffix":""},{"id":469448242,"identity":"464c1449-564b-4730-a93f-05948b3657c5","order_by":3,"name":"Micha Gundelfinger","email":"","orcid":"","institution":"University of Zurich","correspondingAuthor":false,"prefix":"","firstName":"Micha","middleName":"","lastName":"Gundelfinger","suffix":""},{"id":469448243,"identity":"0307e6fb-555b-45d7-a6ce-36e3aa2156ba","order_by":4,"name":"Beate Brand-Saberi","email":"","orcid":"","institution":"Ruhr University Bochum","correspondingAuthor":false,"prefix":"","firstName":"Beate","middleName":"","lastName":"Brand-Saberi","suffix":""},{"id":469448244,"identity":"dfeb1e34-b720-4668-8d57-8428fefee99f","order_by":5,"name":"Thorsten Schäfer","email":"","orcid":"","institution":"Ruhr-University Bochum","correspondingAuthor":false,"prefix":"","firstName":"Thorsten","middleName":"","lastName":"Schäfer","suffix":""}],"badges":[],"createdAt":"2025-06-03 12:53:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6811456/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6811456/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84480433,"identity":"7fee21e1-4af3-4316-9da7-a23e76a3d223","added_by":"auto","created_at":"2025-06-12 12:32:51","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":172237,"visible":true,"origin":"","legend":"\u003cp\u003eThe flowchart illustrates the study selection process following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 396 records were identified via PubMed. After removing 254 studies published in 2020 or earlier, 142 records remained for screening. Of these, 97 were excluded due to a focus on veterinary medicine or clinical research. After eligibility assessment, 45 reports were reviewed in detail, with 25 excluded for lacking relevance to preclinical education or focusing solely on curriculum evaluation. Ultimately, 20 studies were included in the final review, providing insights into CBME implementation in preclinical medical education post-pandemic.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/b159366b34c44957f02dfdb7.png"},{"id":84479132,"identity":"27e9bd0f-cef8-46ab-8caa-399bce59615d","added_by":"auto","created_at":"2025-06-12 12:16:51","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":171997,"visible":true,"origin":"","legend":"\u003cp\u003eA) Proportion of studies incorporating a clinical context versus those focusing solely on preclinical education. B) Geographic distribution of included studies, highlighting key regions contributing to CBME research.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/136beb8a74d455037092882e.png"},{"id":84479966,"identity":"5c20f2c4-6697-4973-9bd2-691a614c811b","added_by":"auto","created_at":"2025-06-12 12:24:51","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":453159,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of study participants across different medical education levels, including undergraduate, preclinical, and clinical training stages.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/7972f3bfa831aaba1ad0ba0f.png"},{"id":84479127,"identity":"4217faf2-cd4a-4830-a700-2d394a0613a8","added_by":"auto","created_at":"2025-06-12 12:16:51","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":107843,"visible":true,"origin":"","legend":"\u003cp\u003eA) Distribution of didactic and methodological focus in CBME studies, categorized into face-to-face, online, and evaluation-based approaches. B) Distribution of study designs, showing the prevalence of different methodological approaches in CBME research.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/05f3da3a04b6f2f3455a9b74.png"},{"id":84479136,"identity":"10e0b15c-f3ce-4344-9475-4821608ba65c","added_by":"auto","created_at":"2025-06-12 12:16:51","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":391054,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of disciplines in CBME studies, highlighting the emphasis on subjects such as anatomy, biochemistry and physiology.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/c09606b1cc411b0b1814f227.png"},{"id":84479138,"identity":"c9ec73b8-c799-4bb7-9d39-55c6ca8b5c5a","added_by":"auto","created_at":"2025-06-12 12:16:51","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":571572,"visible":true,"origin":"","legend":"\u003cp\u003eHeatmap illustrating the distribution of competencies addressed in CBME studies, with different colors indicating their relative importance. Competencies are categorized as follows: PRC (Professional competency), CKS (Clinical knowledge and skills), PKS (Preclinical knowledge and skills), PLS (Practical laboratory skills), COS (Communication skills), TEA (Teamwork), LST (Learning strategies), and TRA (Transfer of knowledge/implementation of preclinical knowledge in clinical practice). Each competency is represented as a main aspect (green), a side aspect (orange), or not mentioned (red).\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/fde1f407c74ed2a9e0528ac2.png"},{"id":84479972,"identity":"5edcf295-ba7c-4451-8354-57ec204857b5","added_by":"auto","created_at":"2025-06-12 12:24:51","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":541385,"visible":true,"origin":"","legend":"\u003cp\u003eHeatmap of teaching formats utilized in competency-based medical education studies. The heatmap illustrates the teaching formats employed across the included studies. Formats are categorized as follows: BLL (Blended learning), CBL (Case-based learning), LTO (Learning through observation), LWS (Lecture combined with workshop/simulation), and SDL (Self-directed learning). Each format is represented as a main aspect (green), a side aspect (orange), or not mentioned (red).\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/2d0408412f9bc5ca1ebd49fc.png"},{"id":91403757,"identity":"0b919b11-6ef0-4677-8190-b575bdd6e585","added_by":"auto","created_at":"2025-09-16 07:30:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3624859,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6811456/v1/f76705b8-9b07-482b-ab9f-090ab74a2ec7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Competency-Based Medical Education in Preclinical Training: Reframing Transformations in the Post-Pandemic Era — a Systematic Review","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMedical education has seen countless trends come and go, each promising to revolutionize how we train future physicians. Some fade into obscurity, others leave a lasting mark \u0026mdash; but Competency-Based Medical Education (CBME) stands apart. Unlike many short-lived innovations, it has been debated, refined, and reimagined for decades, yet it remains a cornerstone of medical education today. And while entire volumes have been written attempting to define what \"competency\" truly means (J. R. Frank et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Leung, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; ten Cate, \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), perhaps it all boils down to this: CBME isn\u0026rsquo;t just about logging hours in lecture halls or completing required rotations. It\u0026rsquo;s about ensuring that medical students don\u0026rsquo;t just go through the motions of training (Harden, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2007\u003c/span\u003e; Voorhees, \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2001\u003c/span\u003e) but actually emerge as competent, capable physicians \u0026mdash; ready for the unpredictable realities of patient care.\u003c/p\u003e \u003cp\u003eRecognizing this need, several frameworks have been introduced to define and operationalize competency domains in medical education (Epstein, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2002\u003c/span\u003e). The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project (1998) placed a strong emphasis on structuring medical training around six core competency domains \u0026mdash; patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice \u0026mdash; shifting the focus from time-based training to assessable, outcome-driven education (Swing, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). These efforts marked a shift away from time-based training models, reinforcing the idea that competence is defined by observable, real-world proficiency rather than the mere completion of curricular milestones. A major step toward structuring these competencies was the CanMEDS initiative, which identified seven key physician roles beyond medical expertise, including communication, collaboration, and leadership (J. Frank, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; J. R. Frank \u0026amp; Danoff, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). More than just a theoretical construct, CanMEDS provided a practical framework for integrating these competencies into curricula and assessments (\u0026ldquo;CanMEDS 2000: Extract from the CanMEDS 2000 Project Societal Needs Working Group Report,\u0026rdquo; 2000; J. Frank, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; J. R. Frank \u0026amp; Danoff, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). However, its implementation highlighted a fundamental challenge: competency is not a fixed set of skills but must be adaptable to context and individual circumstances. Successfully integrating this into curricula is far from trivial, as it requires bridging the gap between theoretical competency frameworks and real-world clinical practice, ensuring that learners are not only assessed on abstract competencies but also on their ability to apply them in complex, dynamic environments (Carraccio et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2002\u003c/span\u003e; ten Cate \u0026amp; Scheele, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). To operationalize this adaptability, the concept of Entrustable Professional Activities (EPAs) was introduced (ten Cate, \u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). While CBME defines competency domains, EPAs translate these into real-world tasks that learners must perform independently before being deemed ready for clinical practice. By linking competence to observable professional activities, EPAs ensure that competency-based education is not merely theoretical but embedded in workplace-based assessment and responsibility (Ten Cate, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This need for a situational and context-sensitive approach to medical education was already recognized by McGaghie et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1978\u003c/span\u003e), who argued that the goal of a competency-based program is not to produce a universally standardized physician but rather one who can practice medicine at a defined level of proficiency, tailored to local needs and conditions (McGaghie et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e1978\u003c/span\u003e). This reinforces the necessity of contextualized competency development, ensuring that medical training prepares learners not only to meet global standards but also to navigate the specific challenges of their future professional environments (Swing, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2010\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eYet, while CBME has provided a structured approach to defining and assessing medical competencies, the COVID-19 pandemic starkly underscored what cannot be easily standardized, virtualized, or assessed through written examinations alone. As medical education rapidly shifted to remote formats (Nikas et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wilhelm et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), relevant elements of physician training \u0026mdash; hands-on procedural skills, real-time clinical decision-making, professional identity formation, and the social and communication skills that make a good physician \u0026mdash; were pushed to the periphery (Rehman et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Saad et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sharma \u0026amp; Bhaskar, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Clinical placements were reduced, peer-to-peer learning diminished, and structured opportunities for developing teamwork, communication, and adaptability \u0026mdash; competencies central to patient-centered care \u0026mdash; became increasingly scarce (Wang et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Professional Identity Formation (Jarvis-Selinger et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), an important aspect of early medical training, was equally affected: Beyond acquiring medical knowledge, students develop their professional roles through experiences that were largely disrupted during the pandemic, particularly in the preclinical years (Henderson et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The COVID-19 pandemic accelerated the adoption of digital learning formats, offering greater flexibility in medical education. However, while online teaching provided logistical advantages, it also came with significant drawbacks, particularly regarding student engagement, peer interaction, and hands-on skill acquisition (Gellisch et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Saad et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sharma \u0026amp; Bhaskar, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Wanigasooriya et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Studies have shown that students trained during this period reported decreased confidence in their practical abilities, with procedural competencies \u0026mdash; such as venipuncture \u0026mdash; being notably affected (Saad et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Performance assessments revealed significantly lower scores in these areas compared to pre-pandemic cohorts (Saad et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These findings align with a recently described phenomenon, the Contextual Digital Divide, which highlights that digital education, due to its inherent limitations, cannot fully meet learning needs in contexts requiring direct interaction and hands-on engagement (Gellisch et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Particularly in skills-based training, digital modalities fail to replicate essential aspects of experiential learning, tutor feedback, and real-time decision-making. These shortcomings are not minor disruptions; they represent a fundamental challenge to the next generation of physicians, who must operate in an increasingly complex healthcare landscape where neither basic knowledge nor technical expertise alone are sufficient.\u003c/p\u003e \u003cp\u003eDespite the success of CBME in clinical training, its integration into the preclinical phase remains conceptually and practically challenging. Basic science courses traditionally emphasize knowledge acquisition over demonstrable competencies, and preclinical curricula often lack structured opportunities for contextual learning or workplace-based assessment. Yet, establishing competence early \u0026mdash; especially in communication, reasoning, and professional attitudes \u0026mdash; is vital to ensure a seamless progression into clinical training. In addition, preclinical medical students faced distinct challenges during the COVID-19 pandemic, including limited access to hands-on learning, reduced peer interaction, and an abrupt transition to remote instruction. These disruptions highlight the need to critically reflect on the lessons learned, ensuring that competency gaps do not persist as medical education continues to evolve in an increasingly digital landscape. To prevent these shortcomings from becoming entrenched in future training models, CBME must be integrated earlier in the curriculum, fostering structured competency development from the outset.\u003c/p\u003e \u003cp\u003e To address this gap, our systematic review explores how CBME has been implemented and adapted in preclinical medical education in the post-pandemic era. By consolidating existing initiatives and innovations, we aim to provide a comprehensive foundation upon which the medical education community can collectively build, ensuring that preclinical training aligns with the evolving demands of competency-based learning.\u003c/p\u003e"},{"header":"Material and Methods","content":" \u003cp\u003e\u003cspan\u003e1. Search strategy\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a systematic literature search in PubMed (MEDLINE\u0026reg; database; National Institutes of Health, United States National Library of Medicine, Bethesda, MD) on October 10, 2024. The search covered articles published between 2021 and 2024, yielding a total of 134 results. To ensure a comprehensive selection of relevant studies, we used the following search query:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e(\u0026quot;competency based medical education\u0026quot;[Title/Abstract] OR \u0026quot;CBME\u0026quot;[Title/Abstract] OR \u0026quot;competency-based curriculum\u0026quot;[Title/Abstract] OR \u0026quot;competency-based training\u0026quot;[Title/Abstract] OR \u0026quot;competency framework\u0026quot;[Title/Abstract] OR \u0026quot;competency\u0026quot;[Title/Abstract]) AND (\u0026quot;preclinical\u0026quot;[Title/Abstract] OR \u0026quot;pre-clinical\u0026quot;[Title/Abstract] OR \u0026quot;basic science\u0026quot;[Title/Abstract] OR \u0026quot;early medical education\u0026quot;[Title/Abstract] OR \u0026quot;early stage medical education\u0026quot;[Title/Abstract]).\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis strategy was designed to capture studies focusing on competency-based medical education (CBME) within the early stages of medical training, ensuring that both broad and specific terminology related to CBME and preclinical education were included.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e2. Study selection and inclusion criteria\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eA total of 396 records were initially identified from PubMed. After excluding 254 records published in 2020 or earlier, 142 remained for screening. Each record was evaluated based on predefined inclusion criteria to ensure relevance and methodological rigor. Studies were included if they focused on human participants within a healthy study population, were peer-reviewed empirical investigations published in academic open-access journals and directly examined Competency-Based Medical Education (CBME) within preclinical training. Additionally, only studies that assessed changes in competency development were considered for inclusion.\u003c/p\u003e\n\u003cp\u003eThis review focused on how CBME evolved in preclinical medical education between 2021 and 2024, particularly in response to the challenges brought about by the COVID-19 pandemic. Lockdowns and restrictions accelerated the adoption of digital learning, prompting educators to develop new approaches that balanced remote instruction with hands-on skill acquisition. Many studies examined how these adaptations influenced students\u0026rsquo; competencies, often comparing different cohorts exposed to varying learning conditions during the pandemic.\u003c/p\u003e\n\u003cp\u003eTo identify relevant studies, we first screened titles and abstracts, excluding articles that did not meet the inclusion criteria, such as those focusing on veterinary medicine, clinical research, or general curriculum evaluations. This initial screening led to the removal of 97 records, leaving 45 studies for further review. After a more detailed assessment, an additional 25 records were excluded for lacking a clear preclinical focus or an explicit evaluation of competency development. Ultimately, 20 studies met all criteria and were included in the final analysis.\u003c/p\u003e\n\u003cp\u003eA careful and unbiased selection process was ensured through an independent review of the studies, followed by the compilation of a list of relevant articles. Any disagreements regarding inclusion were addressed through discussion and full-text review until a consensus was reached. The study selection process is illustrated in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e3. Data extraction\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eA standardized data extraction framework was employed to systematically compile relevant information from the final set of included studies. The extracted variables included authors and year, providing citation details to contextualize the publication, as well as the country of study, reflecting regional variations in CBME implementation. Information on the study population was recorded, specifying the academic level and training stage of participants to ensure relevance to preclinical education. Additionally, the research purpose of each study was documented to highlight its primary focus within the broader CBME framework. The study design was categorized based on methodological approaches, including interventional studies, psychometric validation, and comparative analyses. The educational format was detailed, capturing CBME-aligned instructional methods such as simulation-based learning, case-based learning, or blended learning models. Extracted data also included competency and growth domains, specifying which competencies were targeted, such as clinical reasoning, communication skills, or procedural proficiency. To assess outcomes, information on measured parameters and questionnaires was collected, including multiple-choice quizzes, structured observations, and student feedback surveys. Furthermore, each study\u0026rsquo;s future research recommendations and key results, including statistical findings where applicable, were summarized to provide insights into the effectiveness of CBME adaptations in preclinical education. The final dataset was synthesized to identify overarching trends in CBME implementation, facilitating a structured comparative analysis of how competency-based principles have been integrated into preclinical medical training (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthors (Year)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCountry\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eResearch purpose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStudy design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eEducation format\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCompetency and growth\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMeasured parameters, questionnaires\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFuture research\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eResults\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Burney et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90 preclinical medical students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the effectiveness of a game-based intervention (Patient Communication Challenge) in improving jargon-free patient communication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study with post-workshop surveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGame-based learning, interactive workshops, role-playing, flipped classroom approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePatient-centered communication, health literacy, use of plain language in clinical settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost-workshop self-efficacy survey (5-point Likert scale), free-text qualitative feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo assess long-term skill retention, integrate game into clinical training, expand to other health professions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e91% reported improved proficiency in avoiding jargon, 94% would recommend the workshop, 100% would play again\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Chen et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTaiwan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140 third-year medical students at Taipei Medical University, Taiwan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo investigate whether ultrasound training enhances anatomy learning outcomes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCrossover study with pre- and post-course assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParallel Ultrasound Hands-on (PUSH) course; seven 40-min lectures, two 120-min hands-on practical workshops, small-group learning (1:4 tutor-to-student ratio)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAnatomical knowledge retention, three-dimensional spatial awareness, sonoanatomy skills, self-efficacy in cognitive, affective, and psychomotor learning domains\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWritten midterm and final exam scores (MCQs), laboratory exam on cadavers, self-efficacy questionnaire (5-point Likert scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo assess long-term retention of ultrasound-integrated anatomy training, refine assessment alignment between ultrasound and cadaveric anatomy, explore implementation in other institutions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved midterm written exam scores (7.6% increase, P\u0026thinsp;=\u0026thinsp;0.014, Cohen\u0026rsquo;s d\u0026thinsp;=\u0026thinsp;0.43), no significant improvement in final exam or laboratory test scores, positive student feedback on self-efficacy (Mean\u0026thinsp;=\u0026thinsp;3.68, SD\u0026thinsp;=\u0026thinsp;0.56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Dahmen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e263 (SS2019)\u0026thinsp;+\u0026thinsp;212 (SS 2020) second-semester preclinical medical students at Ulm University, Germany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo compare the impact of transitioning from an Inverted Classroom (IC) format to an online-only format on student satisfaction and biochemistry exam performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObservational comparative study across two cohorts (pre-pandemic IC vs. pandemic-driven online teaching)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInverted Classroom (SS2019) with self-learning phases and in-person teamwork, vs. fully online seminar (SS2020) with pre-recorded lectures, self-directed learning, and online synchronous discussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eBiochemistry knowledge, protein biosynthesis, medical communication, oral exam preparation, and patient consultation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStudent satisfaction survey (Likert scale), free-text feedback evaluation, final biochemistry exam scores (MCQ-based assessment)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate long-term retention of knowledge in different formats, explore blended learning combinations for optimal results\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eComparable student satisfaction in both formats, but significantly higher exam scores in the online cohort (18.3 vs. 15.3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(House et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e167 first-year medical students (and 652 healthcare professionals at the University of Michigan Medical School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the effectiveness of the Interprofessional Clinical Experience (ICE) course using a multimodal approach\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study using student evaluations, preceptor assessments, and competency evaluations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eClinical site visits, experiential learning, reflective assignments, online discussions, and preceptor feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInterprofessional collaboration, communication, teamwork, professionalism, leadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eReadiness for Interprofessional Learning Scale (RIPLS), multiple-choice knowledge quiz, preceptor competency assessments, student course evaluations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eLongitudinal tracking of students into clinical years to assess the lasting impact of ICE training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant improvements in student attitudes toward interprofessional collaboration, increased knowledge of healthcare roles, and strong competency ratings from preceptors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Khan et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e103 first-year medical students (and 6 faculty members at a medical college in North India)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo rapidly transition preclinical practical classes to an online format during COVID-19 and assess the feasibility of the Demonstrate-Engage-Assess Practical Teaching (DEAPP) framework\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-method study (quantitative feedback and qualitative interviews)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOnline teaching using recorded/ live videos, gamified quizzes, MCQs, interactive polling, small group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePractical skills in Anatomy, Physiology and Biochemistry; critical thinking; self-assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStudent satisfaction survey (Likert scale), faculty interviews, self-assessment through quizzes and MCQs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNeed for blended learning (combination of online and offline); improvements in interaction and experiential learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eDEAPP framework was effective, engaging, and resource-efficient, but lacked hands-on experience; students favoured blended learning over fully online formats\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(McMains et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22 first- and second-year healthcare students at East Carolina University Brody School of Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess if students learn, retain, and enjoy emergency medicine (EM)-focused simulation-based learning (SBL)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study with pre-, post-, and delayed retention assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFour SBL events: suturing, medical stabilization (MedEvac), mass casualty triage, point-of-care ultrasound (POCUS); pre-event lectures, hands-on simulation, knowledge quizzes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClinical knowledge retention, procedural skills (suturing, triage, airway management, ultrasound use), emergency medicine decision-making\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePre- and post-event quizzes (MCQs), retention assessments at 20\u0026ndash;100 days, participant satisfaction survey (5-point Likert scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate long-term retention, assess skill transfer to clinical settings, refine SBL curriculum for broader medical education integration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant improvement in knowledge scores post-event (p\u0026thinsp;\u0026le;\u0026thinsp;0.05); no significant decline in knowledge retention over time; high student satisfaction with SBL format\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Michael et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e229 preclinical medical students (and 25 health profession students)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo develop and validate an assessment instrument for structured patient handovers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePsychometric validation study with confirmatory factor analysis (CFA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eVirtual course using Microsoft Teams, simulation-based patient handover training, pre-reading materials, instructional videos\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStructured communication, closed-loop communication, clarifying questions in patient handovers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eBehavioral assessment instrument with 7 items, inter-rater reliability (Krippendorff\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.6245), confirmatory factor analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo expand instrument validation, test across different health professions, assess long-term retention of handover skills, adapt for different structured communication frameworks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eEstablished reliability and preliminary construct validity for handover competency assessment instrument\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Nayak et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e250 first-year MBBS (Bachelor of Medicine and Bachelor of Surgery) students at Kasturba Medical College, Manipal Academy of Higher Education, India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the impact of simulated patient (SP) videos on student learning and satisfaction in an integrated competency-based medical curriculum\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study comparing paper-based clinical cases with SP video-supported cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eIntegrated teaching using clinical linker cases, SP videos, paper-based cases, interactive discussions, and structured teaching modules\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClinical reasoning, patient communication, application of basic science concepts in clinical settings, teamwork in healthcare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStudent feedback surveys (Likert scale), focus group discussions (FGDs), performance on MCQ-based integrated assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate long-term impact of SP videos on knowledge retention, assess effect on clinical skill development, expand study to clinical years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e80% preferred SP videos for understanding clinical relevance, significantly higher test scores in SP video group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), positive student feedback on engagement and integration\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Nguyen et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e121 second-year medical students at Florida International University Herbert Wertheim College of Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo enhance medical students\u0026rsquo; understanding of osteoporosis through an interactive case-based learning session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study with pre- and post-assessment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSmall-group case-based learning (CBL), roundtable discussion, integration of foundational sciences and clinical disciplines, remote learning adaptation (Zoom, Google, Docs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClinical reasoning, osteoporosis diagnosis and management, evidence-based medicine, musculoskeletal physical exam skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFinal exam multiple-choice questions (MCQs), post-session student satisfaction survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePotential improvements include incorporating a baseline readiness assessment and refining osteoporosis-related exam questions for better discrimination\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHigh student performance on session-related exam questions (84%, increasing to 93% after removing an outlier), 94% student satisfaction with session effectiveness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Oh et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e382 dental students (Classes of 2021, 2022, 2023) at the University of Maryland School of Dentistry\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the impact of curriculum modifications on periodontal instrumentation skills development during the COVID-19 pandemic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eObservational study with longitudinal assessment of practical and competency exam scores\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOnsite simulation-based learning (SBL) for Classes of 2021 and 2022, remote SBL for Class of 2023, modified clinical training with restricted patient care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePeriodontal instrumentation, clinical manual skills, dental assessment techniques\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFirst- and second-year practical exams, fourth-year patient-based scaling competency exam, clinic points, multiple linear regression analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate long-term retention of skills, assess digital vs. in-person learning models, optimize preclinical to clinical transition\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo significant difference in fourth-year competency exam scores across classes, clinical experience (clinic points) was the strongest predictor of skill development\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Olson et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e186 first-year medical students at Case Western Reserve University School of Medicine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate obesity education gaps, introduce a new curriculum, and assess its impact on attitudes and knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCurriculum audit, interventional study with pre- and post-surveys, comparison with historical cohort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTeam-based learning (TBL) on obesity pathogenesis and treatment, standardized patient counselling workshops, revised lectures, integrated obesity-related case discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eObesity-related medical knowledge, clinical reasoning, patient counselling, shared decision-making, motivational interviewing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eLikert-scale survey on obesity attitudes and knowledge (pre/post), comparison with historical control group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo improve obesity curriculum in clinical years, enhance knowledge on body composition and physical exams, verify full implementation of recommendations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eImproved obesity knowledge in 14/15 areas (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), reduced bias towards obesity as a personal choice, increased self-efficacy in obesity counselling\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Roberts et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy A: 313 preclinical students, Study B: 62 clinical students, University of Oklahoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess self-directed learning (SDL) readiness and development over time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLongitudinal study with surveys (SDLRS) and qualitative analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSelf-directed learning activities, preclinical and clinical experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSelf-directed learning, critical self-evaluation, self-determination, learning efficacy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-Directed Learning Readiness Scale (SDLRS), thematic qualitative analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo expand qualitative analysis, evaluate curriculum changes to enhance SDL development\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIncreased self-determination scores in preclinical years, qualitative insights into SDL development\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Robertson et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e354 second-year medical students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the impact of an online case-based musculoskeletal module on student learning and performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study with case-based learning and quiz performance analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOnline asynchronous learning, case-based clinical scenarios, multiple-choice quizzes, pre-recorded mini-lectures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMusculoskeletal anatomy, clinical reasoning, diagnostic skills, orthopedic knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModule completion rates, quiz scores, course exam performance (NBME subject exam), student perception survey (Likert scale)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo expand to other institutions, assess long-term retention, integrate clinical experiences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHigher course and NBME exam scores for students completing quizzes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); high module engagement (73% completion rate)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(K. A. Rowe et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUSA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 second-year medical students at Harvard Medical School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate a workshop designed to teach preclinical students how to conduct routine code status discussions (CSDs)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMixed-methods study with pre- and post-surveys (quantitative) and thematic analysis (qualitative)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInteractive workshop using Kern\u0026rsquo;s Six Steps of Curriculum Design, flipped-classroom approach, role-play simulations, small-group discussions, debriefing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCommunication in end-of-life care, shared decision-making, patient-centred discussions, professional role in advance care planning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePre- and post-session self-efficacy assessment (Likert scale), ability to list six code status options, qualitative thematic analysis of concerns and reflections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo assess student performance in real clinical settings, refine the workshop structure, expand study to other institutions, develop longitudinal training for code status discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIncreased knowledge of code status options (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), higher confidence in conducting discussions (19% \u0026rarr; 64%), key concerns: knowledge gaps, fear of upsetting patients\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Sangam et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e200 first-year MBBS students at NRI Medical College and General Hospital, Guntur, India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the effectiveness of case-based learning (CBL) in anatomy education compared to traditional lectures\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional crossover study with pre-test, post-test and retention test assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCase-based learning (CBL), small group discussions (5 groups of 20 students), tutor-facilitated sessions, access to reference materials and internet resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eClinical reasoning, anatomical knowledge retention, self-directed learning, problem-solving skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePre-session MCQ test, post-session MCQ test, retention test (4 weeks later), statistical analysis using t-tests and Chi-square\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo expand the study to multiple institutions, assessing long-term behavioral changes, refining CBL implementation strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eHigher post-session test scores and knowledge retention in CBL group compared to lecture group, statistically significant improvement in learning outcomes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Schneider et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGermany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e155 second-semester medical students at Ulm University, Germany\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the impact of professional actors (standardized patients) vs. peers in communication training within a biochemistry course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eRandomized controlled trial (RCT) comparing two intervention groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCompetency-based inverted classroom setting, role-playing physician-parent consultation, use of standardized patients (SPs) vs. peers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCommunication skills, patient-centred explanations, application of biochemistry knowledge in clinical interactions, CanMEDS roles (Scholar, Communicator, Professional, Medical Expert)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eSelf-perceived competency in CanMEDS roles (9-point Likert scale), student evaluation of role-play realism (6-point Likert scale), summative biochemistry MCQ exam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo incorporate objective communication assessments, explore impact on long-term clinical performance, refine SP training strategies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eBoth SP and peer role-play groups improved self-perceived competencies, SP group showed significantly higher gains in Scholar and Professional roles, no difference in biochemistry exam performance\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Seif et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e110 second-year medical students at Ain Shams University, Egypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo introduce early clinical exposure (ECE) in ECG interpretation using a six-step approach and assess its impact on knowledge and skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInterventional study with pre- and post-assessments\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlended learning, hands-on ECG training, integrated lectures, online forums, cardiology ward visits, case-based discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eECG interpretation, clinical reasoning, diagnostic skills, critical thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMultiple-choice questions (MCQs), Objective Structured Practical Examination (OSPE), student feedback questionnaire, focus group discussions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNeed for more practice opportunities, integration of additional digital resources, potential inclusion of gaming platforms for ECG learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSignificant improvement in ECG interpretation skills, higher post-test scores, positive learner engagement, enhanced self-confidence and motivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Syed Abd Halim et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMalaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 final-year medical students from four public universities in Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo explore how preclinical anatomy education influenced students\u0026rsquo; clinical training and competency in clinical practice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eQualitative phenomenology study using focus group discussions (FGD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eProblem-Based Learning (PBL), cadaveric specimens, anatomy models, didactic lectures, interactive multimedia, and virtual reality applications\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAnatomy knowledge, clinical reasoning, procedural skills (e.g., venous cannulation, catheterization, surface anatomy application), integration of anatomy with clinical diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThematic analysis of focus group discussions, student perceptions on anatomy knowledge application, challenges in anatomy learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate effectiveness of multimodal anatomy teaching, assess long-term knowledge retention, improve clinical integration of anatomy education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eIdentified six key themes: preclinical anatomy learning experience, anatomy content and teaching, anatomy-related competencies, importance of anatomy knowledge in clinical practice, need for early exposure to applied clinical anatomy, recommendations for improving anatomy teaching\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Venkatesh et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150 first-year medical students at Trichy SRM Medical College, India\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo assess the effectiveness of the \"keywords recall\" technique as a formative assessment tool and its correlation with summative performance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eCross-sectional analytical study with multiple assessment methods (MCQs, keyword recall, summative assessments)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTraditional preclinical lectures, formative assessments using MCQs and keyword recall\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eKnowledge retention, formative assessment strategies, test-enhanced learning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFormative assessment scores (MCQs, keyword recall), summative assessment scores, Pearson correlation analysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo expand sample size, test long-term retention, refine keyword recall as an educational intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eKeyword recall scores were higher than MCQ-based formative assessments (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); stronger correlation between keyword recall and summative assessments (r\u0026thinsp;=\u0026thinsp;0.35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e(Zargaran et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUK\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50 pre-clinical and clinical medical students at a higher education institution in the United Kingdom\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTo evaluate the efficacy of high-fidelity simulation training in emergency trauma medicine for undergraduate students\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOne-group pretest-post-test research design\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eConsultant-led lecture, small-group hands-on simulations (chest drain insertion, transoesophageal echocardiogram, splinting), and a simulated major trauma incident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eEmergency medicine procedures, trauma triage, airway management, surgical interventions, teamwork under stress\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePre- and post-training knowledge tests, self-confidence assessment (5-point Likert scale), retention test at six weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eTo investigate long-term retention of emergency medicine competencies, refine simulation scenarios for greater realism, explore integration into standard curricula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e35.8% immediate post-simulation improvement in knowledge, 22.4% improvement at six weeks, 24% increase in confidence in emergency settings (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cspan\u003e1. Study selection and general characteristics\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eOut of the 142 records screened, 20 fully met the inclusion criteria and were included in this review. These studies were consistently published throughout the selected time frame with six studies in 2021, four in 2022, four in 2023, and six in 2024.\u003c/p\u003e\n\u003cp\u003eThe included studies were analyzed based on their integration of a clinical context within CBME. The results showed that more than half of the studies (n\u0026thinsp;=\u0026thinsp;12, 60%) incorporated a clinical perspective, whereas the remaining 40% (n\u0026thinsp;=\u0026thinsp;8) focused exclusively on preclinical education without direct clinical application (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e\n\u003cp\u003eAn analysis of the geographic distribution revealed that the majority of studies were conducted in the United States, which accounted for half of all included studies (n\u0026thinsp;=\u0026thinsp;10, 50%). Other countries contributing to CBME research in preclinical education included India (20%, n\u0026thinsp;=\u0026thinsp;4), Germany (10%, n\u0026thinsp;=\u0026thinsp;2), as well as Egypt, Malaysia, Taiwan, and the United Kingdom, each represented by a single study (5%, n\u0026thinsp;=\u0026thinsp;1) (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e2. Study populations and participants characteristics\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eTo understand the target groups of CBME research, the included studies were categorized based on the educational level of participants. Additionally, the total number of participants in each study was recorded to assess the scale of the investigations. The majority of studies (n\u0026thinsp;=\u0026thinsp;8) focused on first-year medical students, while four studies examined second-year medical students. The remaining studies either investigated a combination of first- and second-year students, other preclinical students, or both preclinical and clinical medical students (Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e2. Didactic and methodological approaches\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThe didactic focus and methodological approaches of the 20 selected studies were analyzed and categorized into three groups: 13 studies (65%) introduced a new face-to-face method, 4 studies (20%) evaluated an existing method, and 3 studies (15%) developed a new online tool. The findings indicate that the majority of studies emphasized the development and assessment of in-person teaching methods, underscoring the role of personal interaction in CBME (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eA). The study designs of the included articles varied considerably. The most common approach was a pre-post study design (n\u0026thinsp;=\u0026thinsp;12; 60%), followed by quasi-experimental designs (n\u0026thinsp;=\u0026thinsp;3; 15%) and observational studies (n\u0026thinsp;=\u0026thinsp;2; 10%). Additionally, two qualitative retrospective studies (10%) and one randomized controlled trial (5%) were included (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eB).\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e4. Preclinical disciplines and integration of clinical competencies\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eWhile the studies primarily focused on preclinical students, half of them incorporated clinical aspects within their competency-based approaches, reflecting an effort to integrate foundational medical knowledge with its practical application. To further examine the specific preclinical disciplines addressed in CBME studies, we analyzed 24 references to subject areas across the included articles, providing insights into the scope and emphasis of competency-based approaches within preclinical education. The results showed that six studies (25%) integrated Anatomy, emphasizing its role in developing spatial understanding of human structures and clinical correlations, particularly in surgical and radiological contexts. Four studies (16.7%) included Biochemistry, often in relation to metabolic pathways and molecular mechanisms relevant to clinical diagnostics and pharmacology. Three studies (12.5%) examined Physiology, highlighting its foundational role in understanding normal and pathological bodily functions, which is relevant for fields such as internal medicine and anaesthesiology. One study (4.17%) addressed other preclinical elements, though without a predominant thematic focus. Only one study (4.17%) explicitly combined both preclinical and clinical competencies, demonstrating an integrated approach where students applied foundational biomedical knowledge to clinical scenarios, such as differential diagnosis or patient case discussions (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e5. Competencies addressed in CBME studies\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eTo provide a structured overview of the competencies targeted in CBME research, a heatmap (Fig. \u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e) was generated. The y-axis lists the included studies based on the first author\u0026rsquo;s name, while the x-axis categorizes the competencies addressed. These competencies include PRC (Professional competency), CKS (Clinical knowledge and skills), PKS (Preclinical knowledge and skills), PLS (Practical laboratory skills), COS (Communication skills), TEA (Teamwork), LST (Learning strategies), and TRA (Transfer of knowledge/ implementation of preclinical knowledge in clinical practice). The color scheme indicates the extent to which each study incorporated a given competency: green represents a primary focus, orange a secondary role, and red indicates that the competency was not considered. The data reveal substantial variation in competency emphasis across studies. While clinical knowledge and teamwork frequently played a central role (green marking), preclinical knowledge and practical laboratory skills were often assigned as secondary role (orange) or omitted altogether (red). This suggests that there is no universal focus on specific competencies in CBME research, but rather a diverse range of methodological approaches.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e6. Teaching formats in CBME studies\u003cbr\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eA second heatmap (Fig. \u003cspan class=\"InternalRef\"\u003e7\u003c/span\u003e) was created to visualize the distribution of teaching formats in CBME. The y-axis lists the analyzed studies, while the x-axis represents the teaching methods investigated, including BLL (Blended learning), CBL (Case-based learning), LTO (Learning through observation), LWS (Lecture combined with workshop/simulation), and SDL (Self-directed learning). The color coding follows the same scheme: green indicates primary focus, orange represents a secondary role, and red denotes that the format was not considered.\u003c/p\u003e\n\u003cp\u003eThe analysis revealed a heterogeneous distribution of teaching formats across CBME studies. Some studies strongly emphasized blended learning or case-based learning (green marking), whereas others mentioned them only as supplementary aspects (orange marking) or omitted them entirely (red marking).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur analysis confirms that CBME is increasingly finding its way into preclinical education in the post-pandemic era. Across different countries and disciplines, medical educators are actively integrating competency-based approaches to bridge the gap between foundational knowledge and real-world application. While CBME has traditionally been emphasized in clinical training, our findings highlight a growing recognition that competency development should begin earlier in the curriculum \u0026mdash; a shift that is reflected in the diverse educational strategies being explored worldwide. Notably, our analysis reveals that the integration of CBME into preclinical education extends beyond theoretical instruction, incorporating competencies in anatomy, physiology, and biochemistry alongside clinical skills, strengthening a more interconnected and applied learning experience. Yet, despite this clear momentum, its implementation remains anything but uniform. Studies vary not only in the teaching methods they employ but also in how these methods are aligned with specific competencies.\u003c/p\u003e \u003cp\u003eOne interesting pattern emerging from our analysis is the remarkable diversity of integrated teaching formats in CBME studies. Rather than relying on singular instructional approaches, the majority of studies employed multiple methods, suggesting a deliberate effort to balance structured guidance with student autonomy (Liu \u0026amp; Sullivan, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Lu et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ricotta et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The patterns observed in the heatmap suggest that case-based learning (CBL) and self-directed learning (SDL) are frequently implemented together, reflecting a pedagogical strategy that strengthens independent problem-solving while ensuring students engage with clinical reasoning in a structured manner. This observation aligns with existing literature, which has demonstrated that the combination of CBL and SDL enhances student learning outcomes while promoting deeper understanding through active engagement with case materials (Tadadaj et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, blended learning (BLL) and lecture-workshop simulations (LWS) often appear in combination, indicating a trend toward integrating digital content with hands-on, interactive components. However, research in this field indicates that high-quality evidence on blended learning in clinical education remains limited (M. Rowe et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Existing studies offer only preliminary support for its effectiveness in enhancing clinical competencies, underscoring the need for more robust, context-sensitive evaluations that account for variations in implementation, learner engagement, and institutional resources before widespread adoption in competency-based medical education (Jebraeily et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; M. Rowe et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2012\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe growing call from the medical education community to integrate CBME into preclinical training comes with the imperative that this transition must be accompanied by innovative teaching designs that move beyond traditional formats, ensuring a more effective and competency-driven learning experience (Joshi, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Our findings suggest that this shift is partly underway, as many studies employ a diverse combination of teaching methodologies (Chen et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Dahmen et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; House et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Nguyen et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Olson et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Roberts et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Sangam et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Schneider et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Seif et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Syed Abd Halim et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Venkatesh et al., \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This trend reflects a promising movement toward aligning preclinical education with CBME principles, ensuring that knowledge acquisition is dynamic, context-dependent, and applied across multiple learning modalities. Rather than prescribing a single best-practice model, these studies suggest that the strength of CBME lies in its adaptability, allowing educators to tailor learning experiences that bridge theoretical knowledge, clinical reasoning, and practical application.\u003c/p\u003e \u003cp\u003eA deeper analysis of our findings reveals distinct patterns in how competencies are addressed within CBME studies. Examining the competency heatmap, it becomes evident that certain competencies frequently appear together, suggesting inherent links in their development and instructional emphasis. This clustering of competencies indicates that competency-based training does not occur in isolation; rather, skills such as communication, teamwork, and professional competency are often cultivated alongside knowledge acquisition and practical skill development.\u003c/p\u003e \u003cp\u003eOur analysis reveals that teamwork (TEA) and communication skills (COS) frequently co-occur in competency-based medical education (CBME), highlighting a close relationship between these two competencies. This alignment is consistent with existing research in medical education, which underscores effective communication as a fundamental element of successful teamwork in clinical practice (Borowczyk et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Lee \u0026amp; Doran, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Lerner et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Given the increasing reliance on interdisciplinary teams in healthcare, the ability to convey information accurately and efficiently is essential \u0026mdash; not only to facilitate seamless collaboration but also to enhance patient safety (Chakraborti et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). This association is further reinforced by guidelines from the Institute of Medicine (IOM) and the Accreditation Council for Graduate Medical Education (ACGME), which recognize team-based healthcare as dependent on a shared foundation of knowledge, skills, and attitudes (KSAs), with communication playing a critical role (Baker et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2005\u003c/span\u003e). Empirical studies suggest that well-structured communication within teams leads to fewer mistakes, enhances error recovery, and ultimately contributes to better patient care (Salas et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2005\u003c/span\u003e; Singh et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2008\u003c/span\u003e; Volpe et al., \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e1996\u003c/span\u003e). As a result, medical education frameworks increasingly advocate for training approaches that explicitly integrate communication-focused activities into teamwork exercises, including simulation-based learning and structured role-playing (Elendu et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Herrera-Aliaga \u0026amp; Estrada, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Sawaya et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFurther, our heatmap analysis clearly demonstrates that preclinical knowledge and skills (PKS) and clinical knowledge and skills (CKS) frequently co-occur in CBME curricula. This recurring pattern across diverse studies highlights a deliberate pedagogical approach, emphasizing the structured integration of foundational knowledge into clinical application. This observation raises an important question: Why do these competencies appear together so frequently, and what does this tell us about how medical education is evolving? One possible explanation is that educational designs integrating both preclinical and clinical elements foster stronger knowledge consolidation, ensuring that basic scientific concepts are not just acquired in isolation but actively reinforced, interconnected, and anchored within clinical practice. This contextualized application strengthens memory traces, enhancing retention and facilitating smoother knowledge transfer to real-world medical scenarios. Research on learning and memory indicates that applying knowledge across various contexts promotes deeper encoding and enhances long-term retention, surpassing the effects of passive exposure (Nelson-Hurwitz \u0026amp; Tagorda, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). This perspective aligns with theories emphasizing active engagement and contextual learning as crucial elements in strengthening memory consolidation and knowledge transfer (Ruiz-Mart\u0026iacute;n \u0026amp; Bybee, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Moreover, when working memory reaches its capacity \u0026mdash; such as during prolonged lectures with continuous information flow \u0026mdash; active learning can enhance retention (Dubinsky \u0026amp; Hamid, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). This provides a neurobiological explanation for why active learning strategies, which intersperse application and interaction, can be more effective in sustaining attention and improving long-term knowledge retention. Teaching designs that integrate PKS and CKS \u0026mdash; such as case-based learning (CBL), blended learning (BLL), and structured simulations \u0026mdash; help alleviate the cognitive load on working memory by actively engaging learners in applying theoretical concepts.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This review sheds light on the increasing efforts to integrate CBME principles into preclinical education, a transition that is both promising and methodologically complex. By mapping these developments across diverse educational contexts, we provide a clear picture of how foundational scientific knowledge and clinical competencies are being linked in meaningful ways. Our analysis further highlights the intellectual and didactic effort required to craft teaching strategies that not only impart knowledge but also actively connect it to practical application \u0026mdash; a shift that is relevant for implementing truly competency-driven learning environments. One of the most compelling takeaways from this review is the emerging pattern of competency synergies: certain skills, when taught together, appear to reinforce each other naturally, creating potential leverage points for more effective curriculum design. These relationships, while promising, remain underexplored and call for deeper empirical investigation. Understanding how competencies interact could unlock valuable synergies and allow educators to design curricula that maximize learning efficiency while minimizing redundancy. Despite these insights, the body of empirical research on CBME in the preclinical phase remains limited. The studies included in this review provide a valuable direction, but there is a pressing need for empirical educational research to rigorously validate and refine these approaches, ensuring that CBME implementation in the preclinical phase is guided by systematic, evidence-based insights. Moving forward, we encourage the medical education community to expand research efforts in this field, ensuring that CBME is not just an ambition for preclinical education \u0026mdash; but a well-supported, evidence-driven reality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to the Zentrum f\u0026uuml;r Medizinische Lehre der Ruhr-Universit\u0026auml;t Bochum (ZML) for the opportunity to engage in stimulating discussions on the integration of CBME in preclinical education. In addition, we would like to express our sincere gratitude to Prof. Dr. med. Johannes Loffing for his valuable content-related guidance and expert advice throughout the development of this manuscript. Our deep appreciation also goes to our colleagues at the Studiendekanat der Universit\u0026auml;ren Medizin Z\u0026uuml;rich for their valuable collegial exchange, which significantly enriched this work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFurthermore, we affirm that large language models were employed solely under the direct guidance and supervision of the authors, with the exclusive purpose of enhancing the clarity and language of this manuscript. The scientific content, analyses, and interpretations remain entirely the original contributions of the authors.\u003c/p\u003e\n\u003cp\u003eFinally, we acknowledge the support of the Open Access Publication Funds of the Ruhr-Universit\u0026auml;t Bochum in facilitating the publication of this work.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBaker, D. P., Salas, E., King, H., Battles, J., \u0026amp; Barach, P. (2005). The Role of Teamwork in the Professional Education of Physicians: Current Status and Assessment Recommendations. \u003cem\u003eThe Joint Commission Journal on Quality and Patient Safety\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(4), 185\u0026ndash;202. https://doi.org/10.1016/S1553-7250(05)31025-7\u003c/li\u003e\n\u003cli\u003eBorowczyk, M., Stalmach-Przygoda, A., Doroszewska, A., Libura, M., Chojnacka-Kuraś, M., Małecki, Ł., Kowalski, Z., \u0026amp; Jankowska, A. K. (2023). Developing an effective and comprehensive communication curriculum for undergraduate medical education in Poland \u0026ndash; the review and recommendations. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 645. https://doi.org/10.1186/s12909-023-04533-5\u003c/li\u003e\n\u003cli\u003eBurney, E., Arora, M., Gaillard, M., Herzig, M., Lester, L., Park, S., \u0026amp; Coleman, C. (2024). A Game-Based Tool for Reducing Jargon Use by Medical Trainees. \u003cem\u003eMedEdPORTAL\u003c/em\u003e. https://doi.org/10.15766/mep_2374-8265.11411\u003c/li\u003e\n\u003cli\u003eCanMEDS 2000: Extract from the CanMEDS 2000 Project Societal Needs Working Group Report. (2000). \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(6), 549\u0026ndash;554. https://doi.org/10.1080/01421590050175505\u003c/li\u003e\n\u003cli\u003eCarraccio, C., Wolfsthal, S. D., Englander, R., Ferentz, K., \u0026amp; Martin, C. (2002). Shifting Paradigms. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e(5), 361\u0026ndash;367. https://doi.org/10.1097/00001888-200205000-00003\u003c/li\u003e\n\u003cli\u003eChakraborti, C., Boonyasai, R. T., Wright, S. M., \u0026amp; Kern, D. E. (2008). A Systematic Review of Teamwork Training Interventions in Medical Student and Resident Education. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(6), 846\u0026ndash;853. https://doi.org/10.1007/s11606-008-0600-6\u003c/li\u003e\n\u003cli\u003eChen, W.-T., Kang, Y.-N., Wang, T.-C., Lin, C.-W., Cheng, C.-Y., Suk, F.-M., Hsu, C.-W., Huang, S.-K., \u0026amp; Huang, W.-C. (2022). Does ultrasound education improve anatomy learning? Effects of the Parallel Ultrasound Hands-on (PUSH) undergraduate medicine course. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 207. https://doi.org/10.1186/s12909-022-03255-4\u003c/li\u003e\n\u003cli\u003eDahmen, L., Schneider, A., Keis, O., Stra\u0026szlig;er, P., K\u0026uuml;hl, M., \u0026amp; K\u0026uuml;hl, S. J. (2022). From the inverted classroom to the online lecture hall: Effects on students\u0026rsquo; satisfaction and exam results. \u003cem\u003eBiochemistry and Molecular Biology Education\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(5), 483\u0026ndash;493. https://doi.org/10.1002/bmb.21650\u003c/li\u003e\n\u003cli\u003eDubinsky, J. M., \u0026amp; Hamid, A. A. (2024). The neuroscience of active learning and direct instruction. \u003cem\u003eNeuroscience \u0026amp; Biobehavioral Reviews\u003c/em\u003e, \u003cem\u003e163\u003c/em\u003e, 105737. https://doi.org/10.1016/j.neubiorev.2024.105737\u003c/li\u003e\n\u003cli\u003eElendu, C., Amaechi, D. C., Okatta, A. U., Amaechi, E. C., Elendu, T. C., Ezeh, C. P., \u0026amp; Elendu, I. D. (2024). The impact of simulation-based training in medical education: A review. \u003cem\u003eMedicine\u003c/em\u003e, \u003cem\u003e103\u003c/em\u003e(27), e38813. https://doi.org/10.1097/MD.0000000000038813\u003c/li\u003e\n\u003cli\u003eEpstein, R. M. (2002). Defining and Assessing Professional Competence. \u003cem\u003eJAMA\u003c/em\u003e, \u003cem\u003e287\u003c/em\u003e(2), 226. https://doi.org/10.1001/jama.287.2.226\u003c/li\u003e\n\u003cli\u003eFrank, J. (2005). \u003cem\u003eThe CanMEDS 2005 physician competency framework. Better standards. Better physicians. Better care.\u003c/em\u003e The Royal College of Physicians and Surgeons of Canada.\u003c/li\u003e\n\u003cli\u003eFrank, J. R., \u0026amp; Danoff, D. (2007). The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 642\u0026ndash;647. https://doi.org/10.1080/01421590701746983\u003c/li\u003e\n\u003cli\u003eFrank, J. R., Mungroo, R., Ahmad, Y., Wang, M., De Rossi, S., \u0026amp; Horsley, T. (2010). Toward a definition of competency-based education in medicine: a systematic review of published definitions. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(8), 631\u0026ndash;637. https://doi.org/10.3109/0142159X.2010.500898\u003c/li\u003e\n\u003cli\u003eGellisch, M., Bablok, M., Morosan-Puopolo, G., Sch\u0026auml;fer, T., \u0026amp; Brand-Saberi, B. (2023). Differences in mental stress parameters of first-year medical students over the three-year course of the ongoing Covid-19 pandemic: A repeated cross-sectional study. \u003cem\u003eBehavioral Sciences\u003c/em\u003e.\u003c/li\u003e\n\u003cli\u003eGellisch, M., Cramer, J., Trenkel, J., B\u0026auml;ker, F., Bablok, M., Morosan-Puopolo, G., Sch\u0026auml;fer, T., \u0026amp; Brand-Saberi, B. (2025). Introducing the contextual digital divide: Insights from microscopic anatomy on usage behavior and effectiveness of digital versus face-to-face learning. \u003cem\u003eAnatomical Sciences Education\u003c/em\u003e, 1\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eGellisch, M., Wolf, O. T., Minkley, N., Kirchner, W. H., Br\u0026uuml;ne, M., \u0026amp; Brand‐Saberi, B. (2022). Decreased sympathetic cardiovascular influences and hormone‐physiological changes in response to Covid‐19‐related adaptations under different learning environments. \u003cem\u003eAnatomical Sciences Education\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(5), 811\u0026ndash;826. https://doi.org/10.1002/ase.2213\u003c/li\u003e\n\u003cli\u003eHarden, R. M. (2007). Outcome-Based Education: the future is today. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 625\u0026ndash;629. https://doi.org/10.1080/01421590701729930\u003c/li\u003e\n\u003cli\u003eHenderson, R. R., Adams, C. A., Thomas, L., Gundersen, E., Zaidi, Z., \u0026amp; Hagen, M. (2024). COVID As a Catalyst: A Qualitative Study Of Professional Identity Formation among U.S. Medical Students During COVID-19. \u003cem\u003eTeaching and Learning in Medicine\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(5), 601\u0026ndash;612. https://doi.org/10.1080/10401334.2023.2240774\u003c/li\u003e\n\u003cli\u003eHerrera-Aliaga, E., \u0026amp; Estrada, L. D. (2022). Trends and Innovations of Simulation for Twenty First Century Medical Education. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e. https://doi.org/10.3389/fpubh.2022.619769\u003c/li\u003e\n\u003cli\u003eHouse, J. B., Cedarbaum, J., \u0026amp; Santen, S. A. (2021). A Multilevel Model for Evaluating Interprofessional Learning. \u003cem\u003eMedical Science Educator\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(2), 349\u0026ndash;353. https://doi.org/10.1007/s40670-020-01193-8\u003c/li\u003e\n\u003cli\u003eJarvis-Selinger, S., MacNeil, K. A., Costello, G. R. L., Lee, K., \u0026amp; Holmes, C. L. (2019). Understanding Professional Identity Formation in Early Clerkship: A Novel Framework. \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e94\u003c/em\u003e(10), 1574\u0026ndash;1580. https://doi.org/10.1097/ACM.0000000000002835\u003c/li\u003e\n\u003cli\u003eJebraeily, M., Pirnejad, H., Feizi, A., \u0026amp; Niazkhani, Z. (2020). Evaluation of blended medical education from lecturers\u0026rsquo; and students\u0026rsquo; viewpoint: a qualitative study in a developing country. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(1), 482. https://doi.org/10.1186/s12909-020-02388-8\u003c/li\u003e\n\u003cli\u003eJoshi, M. K. (2024). Novel teaching\u0026ndash;learning and assessment tools to complement competency-based medical education in postgraduate training. \u003cem\u003eIndian Journal of Anaesthesia\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e(1), 11\u0026ndash;16. https://doi.org/10.4103/ija.ija_1175_23\u003c/li\u003e\n\u003cli\u003eKhan, A. M., Patra, S., Vaney, N., Mehndiratta, M., \u0026amp; Chauhan, R. (2021). Rapid transition to online practical classes in preclinical subjects during COVID-19: Experience from a medical college in North India. \u003cem\u003eMedical Journal Armed Forces India\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e, S161\u0026ndash;S167. https://doi.org/10.1016/j.mjafi.2020.12.030\u003c/li\u003e\n\u003cli\u003eLee, C. T.-S., \u0026amp; Doran, D. M. (2017). The Role of Interpersonal Relations in Healthcare Team Communication and Patient Safety. \u003cem\u003eCanadian Journal of Nursing Research\u003c/em\u003e, \u003cem\u003e49\u003c/em\u003e(2), 75\u0026ndash;93. https://doi.org/10.1177/0844562117699349\u003c/li\u003e\n\u003cli\u003eLerner, S., Magrane, D., \u0026amp; Friedman, E. (2009). Teaching Teamwork in Medical Education. \u003cem\u003eMount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine\u003c/em\u003e, \u003cem\u003e76\u003c/em\u003e(4), 318\u0026ndash;329. https://doi.org/10.1002/msj.20129\u003c/li\u003e\n\u003cli\u003eLeung, W.-C. (2002). Competency based medical training: review. \u003cem\u003eBMJ (Clinical Research Ed.)\u003c/em\u003e, \u003cem\u003e325\u003c/em\u003e(7366), 693\u0026ndash;696.\u003c/li\u003e\n\u003cli\u003eLiu, T.-H., \u0026amp; Sullivan, A. M. (2021). A story half told: a qualitative study of medical students\u0026rsquo; self-directed learning in the clinical setting. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 494. https://doi.org/10.1186/s12909-021-02913-3\u003c/li\u003e\n\u003cli\u003eLu, S. Y., Ren, X. P., Xu, H., \u0026amp; Han, D. (2023). Improving self-directed learning ability of medical students using the blended teaching method: a quasi-experimental study. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 616. https://doi.org/10.1186/s12909-023-04565-x\u003c/li\u003e\n\u003cli\u003eMcGaghie, W. C., Miller, G. E., Sajid, A. W., \u0026amp; Telder, T. V. (1978). Competency-based curriculum development on medical education: an introduction. \u003cem\u003ePublic Health Papers\u003c/em\u003e, \u003cem\u003e68\u003c/em\u003e, 11\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eMcMains, J. C., Larkins, M. C., Doherty, A. M., Horiates, J., Alachraf, K., Gordon, J. A., Fletcher, J., \u0026amp; Brewer, K. L. (2023). Knowledge Retention From Emergency Medicine Simulation-Based Learning Curriculum for Pre-clinical Medical Students. \u003cem\u003eCureus\u003c/em\u003e. https://doi.org/10.7759/cureus.41216\u003c/li\u003e\n\u003cli\u003eMichael, M., Griggs, A. C., Shields, I. H., Sadighi, M., Hernandez, J., Chan, C., McHugh, M., Nichols, B. E., Joshi, K., Testa, D., Raj, S., Preble, R., Lazzara, E. H., \u0026amp; Greilich, P. E. (2021). Improving handover competency in preclinical medical and health professions students: establishing the reliability and construct validity of an assessment instrument. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 518. https://doi.org/10.1186/s12909-021-02943-x\u003c/li\u003e\n\u003cli\u003eNayak, K. R., Nayak, V., Punja, D., Badyal, D. K., \u0026amp; Modi, J. N. (2023). Simulated patient videos to supplement integrated teaching in competency-based undergraduate medical curriculum. \u003cem\u003eAdvances in Physiology Education\u003c/em\u003e, \u003cem\u003e47\u003c/em\u003e(2), 296\u0026ndash;306. https://doi.org/10.1152/advan.00167.2022\u003c/li\u003e\n\u003cli\u003eNelson-Hurwitz, D. C., \u0026amp; Tagorda, M. (2015). Developing an undergraduate applied learning experience. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e, 2. https://doi.org/10.3389/fpubh.2015.00002\u003c/li\u003e\n\u003cli\u003eNguyen, B., Athauda, G., Kashan, S. B., Weiler, T., \u0026amp; Toonkel, R. L. (2021). Osteoporosis: A Small-Group Case-Based Learning Activity. \u003cem\u003eMedEdPORTAL\u003c/em\u003e. https://doi.org/10.15766/mep_2374-8265.11176\u003c/li\u003e\n\u003cli\u003eNikas, I. P., Lamnisos, D., Meletiou‐Mavrotheris, M., Themistocleous, S. C., Pieridi, C., Mytilinaios, D. G., Michaelides, C., \u0026amp; Johnson, E. O. (2022). Shift to emergency remote preclinical medical education amidst the Covid‐19 pandemic: A single‐institution study. \u003cem\u003eAnatomical Sciences Education\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 27\u0026ndash;41. https://doi.org/10.1002/ase.2159\u003c/li\u003e\n\u003cli\u003eOh, S., Mishler, O., Syme, S., Jones, D., \u0026amp; Saito, H. (2024). Impact of the modified curricula on periodontal instrumentation skills development during the COVID‐19 pandemic from 2020 to 2023. \u003cem\u003eJournal of Dental Education\u003c/em\u003e, \u003cem\u003e88\u003c/em\u003e(11), 1503\u0026ndash;1510. https://doi.org/10.1002/jdd.13632\u003c/li\u003e\n\u003cli\u003eOlson, A., Watowicz, R., Seeholzer, E., Lyons, K., Butsch, W. S., \u0026amp; Croniger, C. (2024). Preclinical obesity curriculum: audit, implementation, and evaluation. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1), 639. https://doi.org/10.1186/s12909-024-05606-9\u003c/li\u003e\n\u003cli\u003eRehman, M., Khalid, F., Sheth, U., Al-Duaij, L., Chow, J., Azim, A., Last, N., Blissett, S., \u0026amp; Sibbald, M. (2024). Quarantining From Professional Identity: How Did COVID-19 Impact Professional Identity Formation in Undergraduate Medical Education? \u003cem\u003ePerspectives on Medical Education\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(1). https://doi.org/10.5334/pme.1308\u003c/li\u003e\n\u003cli\u003eRicotta, D. N., Richards, J. B., Atkins, K. M., Hayes, M. M., McOwen, K., Soffler, M. I., Tibbles, C. D., Whelan, A. J., \u0026amp; Schwartzstein, R. M. (2022). Self-Directed Learning in Medical Education: Training for a Lifetime of Discovery. \u003cem\u003eTeaching and Learning in Medicine\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(5), 530\u0026ndash;540. https://doi.org/10.1080/10401334.2021.1938074\u003c/li\u003e\n\u003cli\u003eRoberts, M., Darden, A., Wiskur, B., \u0026amp; Hill, M. (2024). A Longitudinal Assessment of Self-directed Learning Readiness and Development in Medical Students. \u003cem\u003eJournal of Medical Education and Curricular Development\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e. https://doi.org/10.1177/23821205241242261\u003c/li\u003e\n\u003cli\u003eRobertson, K., McNulty, M. A., Natoli, R. M., Stout, J., \u0026amp; Ulrich, G. (2024). Musculoskeletal Clinical Online Cases With a Focus on Anatomy for Preclinical Learners. \u003cem\u003eMedEdPORTAL\u003c/em\u003e. https://doi.org/10.15766/mep_2374-8265.11457\u003c/li\u003e\n\u003cli\u003eRowe, K. A., Ouchi, K., Kennedy, M., Breu, A., Tolchin, D. W., \u0026amp; Schwartz, A. W. (2024). Preparing Preclinical Medical Students for Routine Code Status Discussions: A Mixed-Methods Study. \u003cem\u003eJournal of Pain and Symptom Management\u003c/em\u003e, \u003cem\u003e67\u003c/em\u003e(2), 138\u0026ndash;146. https://doi.org/10.1016/j.jpainsymman.2023.10.017\u003c/li\u003e\n\u003cli\u003eRowe, M., Frantz, J., \u0026amp; Bozalek, V. (2012). The role of blended learning in the clinical education of healthcare students: A systematic review. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(4), e216\u0026ndash;e221. https://doi.org/10.3109/0142159X.2012.642831\u003c/li\u003e\n\u003cli\u003eRuiz-Mart\u0026iacute;n, H., \u0026amp; Bybee, R. W. (2022). The cognitive principles of learning underlying the 5E Model of Instruction. \u003cem\u003eInternational Journal of STEM Education\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(1), 21. https://doi.org/10.1186/s40594-022-00337-z\u003c/li\u003e\n\u003cli\u003eSaad, S., Richmond, C., King, D., Jones, C., \u0026amp; Malau-Aduli, B. (2023). The impact of pandemic disruptions on clinical skills learning for pre-clinical medical students: implications for future educational designs. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(1), 364. https://doi.org/10.1186/s12909-023-04351-9\u003c/li\u003e\n\u003cli\u003eSalas, E., Sims, D. E., \u0026amp; Burke, C. S. (2005). Is there a \u0026ldquo;Big Five\u0026rdquo; in Teamwork? \u003cem\u003eSmall Group Research\u003c/em\u003e, \u003cem\u003e36\u003c/em\u003e(5), 555\u0026ndash;599. https://doi.org/10.1177/1046496405277134\u003c/li\u003e\n\u003cli\u003eSangam, M. R., K, P., G, V., Bokan, R. R., Deka, R., \u0026amp; Kaur, A. (2021). Efficacy of Case-Based Learning in Anatomy. \u003cem\u003eCureus\u003c/em\u003e. https://doi.org/10.7759/cureus.20472\u003c/li\u003e\n\u003cli\u003eSawaya, R. D., Mrad, S., Rajha, E., Saleh, R., \u0026amp; Rice, J. (2021). Simulation-based curriculum development: lessons learnt in Global Health education. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 33. https://doi.org/10.1186/s12909-020-02430-9\u003c/li\u003e\n\u003cli\u003eSchneider, A., Messerer, D. A. C., K\u0026uuml;hn, V., Horneffer, A., Bugaj, T. J., Nikendei, C., K\u0026uuml;hl, M., \u0026amp; K\u0026uuml;hl, S. J. (2022). Randomised controlled monocentric trial to compare the impact of using professional actors or peers for communication training in a competency-based inverted biochemistry classroom in preclinical medical education. \u003cem\u003eBMJ Open\u003c/em\u003e, \u003cem\u003e12\u003c/em\u003e(5), e050823. https://doi.org/10.1136/bmjopen-2021-050823\u003c/li\u003e\n\u003cli\u003eSeif, A. A., Eldamanhoury, H. M., Darahim, K., Boulos, D. N. K., Bahaa, N., A M, C., Velladath, S. U., \u0026amp; Kamath, M. G. (2021). EE-6S: an integrated approach for introducing early clinical exposure in the new Egyptian medical curriculum. \u003cem\u003eAdvances in Physiology Education\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(1), 109\u0026ndash;120. https://doi.org/10.1152/advan.00166.2020\u003c/li\u003e\n\u003cli\u003eSharma, D., \u0026amp; Bhaskar, S. (2020). Addressing the Covid-19 Burden on Medical Education and Training: The Role of Telemedicine and Tele-Education During and Beyond the Pandemic. \u003cem\u003eFrontiers in Public Health\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e. https://doi.org/10.3389/fpubh.2020.589669\u003c/li\u003e\n\u003cli\u003eSingh, H., Naik, A. D., Rao, R., \u0026amp; Petersen, L. A. (2008). Reducing diagnostic errors through effective communication: harnessing the power of information technology. \u003cem\u003eJournal of General Internal Medicine\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(4), 489\u0026ndash;494. https://doi.org/10.1007/s11606-007-0393-z\u003c/li\u003e\n\u003cli\u003eSwing, S. R. (2007). The ACGME outcome project: retrospective and prospective. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(7), 648\u0026ndash;654. https://doi.org/10.1080/01421590701392903\u003c/li\u003e\n\u003cli\u003eSwing, S. R. (2010). Perspectives on competency-based medical education from the learning sciences. \u003cem\u003eMedical Teacher\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(8), 663\u0026ndash;668. https://doi.org/10.3109/0142159X.2010.500705\u003c/li\u003e\n\u003cli\u003eSyed Abd Halim, S. A., Yusoff, M. S. B., Yaman, M. N., Razali, S. A., Tengku Muda, T. F. M., Ramli, R. R., Kadir, F., \u0026amp; Hadie, S. N. H. (2023). Clinical students\u0026rsquo; reflections on the preclinical anatomy learning experience. \u003cem\u003eJournal of Taibah University Medical Sciences\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(4), 757\u0026ndash;770. https://doi.org/10.1016/j.jtumed.2022.12.007\u003c/li\u003e\n\u003cli\u003eTadadaj, C., Wannapiroon, P., \u0026amp; Sillabutra, J. (2022). Case-Based Learning in Self-directed Learning Environment using a Digital Platform to Enhance Public Health Students\u0026rsquo; Learning Outcome in Graduate Study. \u003cem\u003eTEM Journal\u003c/em\u003e, 1653\u0026ndash;1659. https://doi.org/10.18421/TEM114-28\u003c/li\u003e\n\u003cli\u003eten Cate, O. (2005). Entrustability of professional activities and competency-based training. \u003cem\u003eMedical Education\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(12), 1176\u0026ndash;1177. https://doi.org/10.1111/j.1365-2929.2005.02341.x\u003c/li\u003e\n\u003cli\u003eTen Cate, O. (2013). Nuts and bolts of entrustable professional activities. \u003cem\u003eJournal of Graduate Medical Education\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(1), 157\u0026ndash;158. https://doi.org/10.4300/JGME-D-12-00380.1\u003c/li\u003e\n\u003cli\u003eten Cate, O. (2017). \u003cem\u003eCompetency-Based Medical Education and its Competency Frameworks\u003c/em\u003e (pp. 903\u0026ndash;929). https://doi.org/10.1007/978-3-319-41713-4_42\u003c/li\u003e\n\u003cli\u003eten Cate, O., \u0026amp; Scheele, F. (2007). Viewpoint: Competency-Based Postgraduate Training: Can We Bridge the Gap between Theory and Clinical Practice? \u003cem\u003eAcademic Medicine\u003c/em\u003e, \u003cem\u003e82\u003c/em\u003e(6), 542\u0026ndash;547. https://doi.org/10.1097/ACM.0b013e31805559c7\u003c/li\u003e\n\u003cli\u003eVenkatesh, K., Muthukumar, D., Kamala, E., \u0026amp; Muhil, M. (2024). Study of Efficacy of a Novel Formative Assessment Tool: Keywords Recall. \u003cem\u003eCureus\u003c/em\u003e. https://doi.org/10.7759/cureus.69881\u003c/li\u003e\n\u003cli\u003eVolpe, C. E., Cannon-Bowers, J. A., Salas, E., \u0026amp; Spector, P. E. (1996). The Impact of Cross-Training on Team Functioning: An Empirical Investigation. \u003cem\u003eHuman Factors: The Journal of the Human Factors and Ergonomics Society\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(1), 87\u0026ndash;100. https://doi.org/10.1518/001872096778940741\u003c/li\u003e\n\u003cli\u003eVoorhees, A. B. (2001). Creating and Implementing Competency‐Based Learning Models. \u003cem\u003eNew Directions for Institutional Research\u003c/em\u003e, \u003cem\u003e2001\u003c/em\u003e(110), 83\u0026ndash;95. https://doi.org/10.1002/ir.13\u003c/li\u003e\n\u003cli\u003eWang, W., Li, G., \u0026amp; Lei, J. (2024). The impact of COVID-19 on medical students. \u003cem\u003eGMS Journal for Medical Education\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(1), Doc10. https://doi.org/10.3205/zma001665\u003c/li\u003e\n\u003cli\u003eWanigasooriya, K., Beedham, W., Laloo, R., Karri, R. S., Darr, A., Layton, G. R., Logan, P., Tan, Y., Mittapalli, D., Patel, T., Mishra, V. D., Odeh, O., Prakash, S., Elnoamany, S., Peddinti, S. R., Daketsey, E. A., Gadgil, S., Bouhuwaish, A. E. M., Ozair, A., \u0026hellip; Ashpak, A. (2021). The perceived impact of the Covid-19 pandemic on medical student education and training \u0026ndash; an international survey. \u003cem\u003eBMC Medical Education\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 566. https://doi.org/10.1186/s12909-021-02983-3\u003c/li\u003e\n\u003cli\u003eWilhelm, J., Mattingly, S., \u0026amp; Gonzalez, V. H. (2022). Perceptions, satisfactions, and performance of undergraduate students during Covid‐19 emergency remote teaching. \u003cem\u003eAnatomical Sciences Education\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(1), 42\u0026ndash;56. https://doi.org/10.1002/ase.2161\u003c/li\u003e\n\u003cli\u003eZargaran, A., Houlden, R., O\u0026rsquo;Neill, P., Schaffer, S., Chang, V., Kafai Golahmadi, A., Hirniak, J., Turki, M., \u0026amp; Zargaran, D. (2022). Emergency medicine undergraduate simulation training during the COVID-19 pandemic: A course evaluation. \u003cem\u003eInjury\u003c/em\u003e, \u003cem\u003e53\u003c/em\u003e(10), 3191\u0026ndash;3194. https://doi.org/10.1016/j.injury.2022.07.003\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6811456/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6811456/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eCompetency-Based Medical Education (CBME) has evolved over decades, prioritizing real-world proficiency over traditional, time-based training. While its application has been well established in clinical education, its integration into the preclinical phase is gaining traction, particularly in response to the challenges highlighted by the COVID-19 pandemic. The shift to digital learning formats disrupted hands-on training, peer interaction, and professional identity formation, underscoring the need for structured competency development early in medical education.\u003c/p\u003e \u003cp\u003e This systematic review explores how CBME principles are being incorporated into preclinical education, examining diverse teaching methodologies and their role in bridging the gap between foundational knowledge and clinical application. By employing a structured analysis of competency frameworks, we identified recurring patterns in the alignment of educational strategies with targeted learning outcomes. Our findings reveal that certain competency domains frequently co-occur in more elaborate instructional designs, suggesting inherent synergies that may support both knowledge retention and transferability.\u003c/p\u003e \u003cp\u003eWhile these developments mark progress, the field still lacks a comprehensive, empirically validated framework for CBME implementation in preclinical education. More systematic research is needed to refine best practices, optimize instructional approaches, and harness the potential synergy between competencies. Strengthening the evidence base will be essential for guiding the future integration of CBME, ensuring that competency-driven education begins early and effectively prepares students for the evolving demands of medical practice.\u003c/p\u003e","manuscriptTitle":"Competency-Based Medical Education in Preclinical Training: Reframing Transformations in the Post-Pandemic Era — a Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-12 12:16:46","doi":"10.21203/rs.3.rs-6811456/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1e69a33d-ad41-44d1-9e2c-ef7b8625e56f","owner":[],"postedDate":"June 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-09-16T05:39:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-12 12:16:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6811456","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6811456","identity":"rs-6811456","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}