Research on the Application of CBL Combined with OSCE in the Teaching of Anorectal Standardized Training Physician of Traditional Chinese Medicine

Research on the Application of CBL Combined with OSCE in the Teaching of Anorectal Standardized Training Physician of Traditional Chinese Medicine | 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 Research on the Application of CBL Combined with OSCE in the Teaching of Anorectal Standardized Training Physician of Traditional Chinese Medicine Linhui Li, Shuangxi Zhang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7287583/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Objective ：To explore the application effect of case-based learning ( CBL ) combined with objective structured clinical examination ( OSCE ) in the standardized training of anorectal residents of traditional Chinese medicine. Methods ：From June 2023 to December 2024, 60 residents who received standardized training of residents in the anorectal department of the First Affiliated Hospital of Henan University of Tradit ional Chinese Medicine were randomly divided into experimental group ( CBL + OSCE, n = 30 ) and control group ( traditional teaching, n = 30 ). The teaching effects of different teaching methods were evaluated by comparing the examination results ( theory, skill operation, case analysis ), teaching satisfaction and clinical thinking ability of the two groups. Results ：The scores of theoretical achievement ( 89.5 ± 4.2 vs. 82.1 ± 5.6 ), skill operation ( 91.3 ± 3.8 vs. 85.4 ± 4.5 ), case analysis ( 93.2 ± 2.9 vs. 87.6 ± 3.7 ), teaching satisfaction and clinical thinking ability in the experimental group were significantly higher than those in the control group ( all P < 0.05 ). Conclusion ：With the advantages of combining theory with practice, the CBL combined with OSCE teaching mode realizes the integrated training of Chinese and Western medicine diagnosis and treatment ability for the firs t time in the anorectal training of traditional Chinese medicine, which significantly improves the teaching effect and provides an innovative solution for the training of anorectal professionals of traditional Chinese medicine. CBL OSCE Traditional Chinese Medicine Anorectal Department standardized training of residents integrated Traditional Chinese and Western Medicine Teaching Introduction Anorectal science of traditional Chinese medicine (TCM), as a special branch of TCM, has a long history and rich clinical experience in China. With the development of modern medicine, the demand for TCM anorectal professionals is growing, and the importance of TCM anorectal training teaching has become increasingly prominent. Standardized resident training is an important part of post-graduate education for medical students and an effective way to cultivate excellent clinicians [1] . However, the current planning and training teaching is still dominated by teachers, students passively accept knowledge, the lack of clinical thinking training, and assessment depends on theoretical written examination, focusing on theoretical memory, ignoring the evaluation of practical ability and communication skills, TCM characteristic diagnosis and treatment and the integration of modern technology teaching case is less, it is difficult to fully assess the practical ability of students [2] . Case-Based Learning (CBL) is based on real cases, and guides students to solve practical problems through analysis and discussion. it can improve students' learning interest and initiative, and cultivate students' clinical thinking ability and problem-solving ability [3] . Objective structured clinical examination (OSCE) is an objective and comprehensive assessment model. it can effectively evaluate the clinical ability of students by setting up multiple examination stations, simulating the actual clinical scenarios, and comprehensively assessing their clinical skills, communication ability, and professional quality [4] . In recent years, CBL and OSCE have been gradually promoted in medical education, but their application in the field of traditional Chinese medicine (TCM) anorectal still lacks high-quality research. In this study, the two were innovatively combined, and the case and assessment site was designed according to the characteristics of diagnosis and treatment of integrated Chinese and Western medicine in anorectal department. The purpose of the study was to give full play to the advantages of the two, improve the quality of teaching, explore the optimal path suitable for the teaching of integrated Chinese and Western medicine, and cultivate Chinese anorectal professionals with a solid theoretical basis, skilled clinical skills and good professional quality. This not only fills the gap in the teaching mode of TCM anorectal field, helps to improve the overall level of TCM anorectal subject, but also better meets the needs of patients for high quality medical service, which has important practical significance. 1 Study Object Sixty residents who received standardized resident training in the Department of Coloproctology and Gastroenterology, the First Affiliated Hospital of Henan University of Chinese Medicine from June 2023 to December 2024 were selected as the research subjects in this study. All residents participated in standardized training for residents in Henan Province, and the training period in the Coloproctology Department was two months. Inclusion criteria: voluntary participation in the study; Standardized training for anorectal specialty in traditional Chinese medicine is being conducted; Have certain basic medical knowledge. Exclusion criteria were: physicians who dropped out of the training or were unable to complete the entire study due to special reasons. This study was approved by the Ethics Committee of Henan University of Traditional Chinese Medicine and the case data were desensitized. SPSS 22.0 was used to generate a random sequence, and independent researchers assigned the subjects to groups. The teachers and students were unaware of the grouping (single-blind method). The subjects were divided into an experimental group (CBL + OSCE) and a control group (traditional teaching), 30 in each group. The balance test of the two groups of discipline physicians in age, gender, and enrollment performance showed no statistically significant difference (P > 0.05), with comparability. See Table 1 . Table 1 Comparison of general conditions between the two groups group Number of cases Age (years,‾X ± s Gender (male/female) Basic scores (score,‾X ± s) control group 30 22.3 ± 1.3 15/15 75.1 ± 9.5 Experimental group 30 22.5 ± 1.2 14/16 76.2 ± 9.8 T/χ2 value - t = 0.62 χ²=0.27 t = 0.44 P value - p = 0.537 p = 0.604 p = 0.663 Note: the differences were not statistically significant (p > 0.05) 2 Teaching methods 2.1 control group (traditional teaching group) According to the Management Methods of Standardized Training for Resident Doctors in Henan Province, during the standardized training of resident doctors in our department, a learning seminar related to basic clinical knowledge and skills was held once a week in the department. The clinical teaching teachers used PPT to teach, and focused on explaining the pathogenesis, pathophysiology, clinical manifestations, diagnosis and differential diagnosis, treatment and prognosis of common anorectal diseases to the planning and training physicians according to the requirements of the teaching syllabus. At the same time, practical operation skills were trained. 2.2 Test group (CBL + OSCE group) 2.2.1 CBL teaching implementation (1) Case selection. The instructor selected the patients of typical cases (mixed hemorrhoids, anal fissure, anal fistula, and perianal abscess) in the Coloproctology Department of our hospital as the object of case discussion, and distributed the materials to the students in advance, so that the students could consult the materials before class to further understand the disease, and proposed the common clinical problems. (2) Question posing: The teacher guided the students to comprehensively collect medical records and physical examination information, and put forward positioning diagnosis and qualitative diagnosis problems, including disease type, staging and cause, through imaging reading and analysis, whether further examination was needed. (3) Problem analysis: Combined with the actual cases, in view of the proposed problems, the teachers organized the students to discuss in groups, and conducted a comprehensive analysis of the case history, physical examination and auxiliary examination data, in order to correct the wrong understanding in the discussion among the students in time and formulate the correct diagnosis and treatment plan. At the same time, in response to the questions raised by the students, the teacher should guide them to think independently, such as applying the knowledge learned to analyze the problems, or consulting the answers to the problems with the help of the literature and the network, so as to give full guidance to the teacher, rather than directly answering the questions. (4) Summary: After the group discussion, the teacher should systematically and retrospectively analyze and explain the relevant cases, summarize the discussion topics, correct the wrong views of the students, give a detailed lecture on the definition, type, etiology and standardized diagnosis of anorectal diseases, and introduce some international cutting-edge theories and technologies related to anorectal medicine to the students. 2.2.2 Implementation of OSCE assessment (1) personnel organization Before the assessment, the establishment of a special assessment of the leading group, responsible for the organization of the examiner training, the development of assessment programs, coordination of assessment sites and materials and other work. The examiner shall be the attending physician or deputy director physician with rich clinical experience and teaching experience, and conduct unified training before the examination, so as to ensure that the examiner is familiar with the examination procedures, scoring standards and requirements, and ensure the fairness and accuracy of the examination. The interexaminer consistency test in the preliminary experiment showed that the Kappa coefficient was 0.85(P < 0.01). (2) site settings After the examinee enters the examination hall, first carries on the identity authentication, after the confirmation examinee information is correct, guides the examinee to enter the waiting examination area. Waiting area set up a special staff, responsible for maintaining order, to introduce candidates assessment process and matters needing attention. According to the order of drawing lots, the examinees enter each test station in turn for examination. Five standardized test stations were set up to simulate the real clinical scenarios. The assessment time for each test station was 15 minutes, and the candidates completed the corresponding assessment tasks within the prescribed time. Professional ability accounted for 80% (operational accuracy and standardization), and communication ability accounted for 20% (language expression and patient interaction). See Table 2 : Table 2 OSCE site settings station Assessment content core competence Scoring criteria (100 points) 1. History collection Simulating a visiting scene of a mixed hemorrhoid/anal fissure patient Interrogation techniques Interrogation integrity 2. Physical examination Anoscopy, digital rectal examination, anoscopy Specialty physical examination standardization Physical examination standardization 3. TCM skills operation Chinese medicine fumigating and washing, acupuncture and moxibustion Characteristic treatment skills of traditional chinese medicine Square-certificate fit degree 4. western medicine skills operation Debridement, suture and dressing change Basic operation of western medicine surgery Operational proficiency 5. Comprehensive case analysis Complex case (high complex anal fistula complicated with diabetes mellitus) Multidisciplinary diagnosis and treatment thinking, individual treatment plan Programme comprehensiveness Note: special rule: in site 5, 10 points will be deducted if participants fail to voluntarily mention multi-disciplinary diagnosis and treatment. (3)OSCE implementation First stop: history taking It mainly examines the students' ability to communicate with patients and obtain accurate medical history information. Students need to accurately understand the patient's condition within the stipulated time by asking questions about the patient's symptoms, onset time, past medical history, and family medical history. For example, in the face of a patient with hematochezia, students need to ask in detail the color, quantity and frequency of hematochezia, whether there are accompanied by symptoms such as pain and prolapse, as well as the patient's eating habits, daily life and rest, and so on and so forth, to provide the basis for the subsequent diagnosis and treatment. Second stop: physical examination Students are required to be familiar with the methods and skills of physical examination in TCM anorectal specialty. Students need to conduct anoscopy, digital rectal examination, and anoscopy to accurately judge the patient's condition. When inspecting the anus, observe whether there is any mass, fissure, swelling, secretion, etc. around the anus; Rectal digital diagnosis, feel the hardness of the rectal wall, the presence of masses, tenderness, stenosis, etc.; During anoscopy, the anal canal and rectal mucosa are observed, including internal hemorrhoid, ulcer and hemorrhage. Third stop: TCM skill manipulation Focus on the students' traditional Chinese medicine treatment skills. Including Chinese medicine fumigation, Chinese medicine sitz bath, acupuncture, massage, etc. Taking Chinese medicine fumigation as an example, students need to accurately formulate Chinese medicine prescriptions according to the patient's condition, and master the temperature, time and method of fumigation to ensure the therapeutic effect. In acupuncture manipulation, students should be familiar with the positioning of acupoints, the angle and depth of insertion of acupuncture, and the manipulation of acupuncture. Fourth stop: western medicine skill operation It mainly inspects students' basic operation skills of western medicine surgery. In debridement and suture, students need to correctly handle the wound, disinfection, hemostasis, suture and other operations to ensure good wound healing. Dressing change, should strictly abide by the principle of aseptic operation, correct change dressings, observe the wound healing. Station 5: case analysis Students are required to comprehensively use the knowledge learned to analyze and diagnose a given case and propose a reasonable treatment. Students need to conduct TCM syndrome differentiation and western medicine diagnosis according to the information of medical history, physical examination, auxiliary examination and so on, to develop a treatment plan of TCM and western medicine. For patients with high complex anal fistula complicated with diabetes, students need to analyze the etiology and pathogenesis from the perspective of traditional Chinese medicine (TCM) to determine the syndrome type, and adopt the methods of oral administration and external application of TCM to treat it. At the same time, the type and degree of anal fistula were clarified from the perspective of western medicine, and the appropriate surgical method was selected for treatment. (4)OSCE score The scoring of each test station includes two aspects: professional ability and communication ability. The professional ability scoring is mainly based on the students' operation accuracy, standardization, proficiency as well as the mastery and application ability of knowledge in the test station. At the medical history collection and examination station, the key points of professional ability scoring include the comprehensiveness and accuracy of asking the medical history, the ability to grasp key information, and whether the preliminary condition analysis can be conducted according to the medical history. In the physical examination station, the main points of scoring include the correctness of the examination method, the standardization of operation, and the accurate judgment ability of physical signs. In the TCM skill manipulation test station, the scoring points included the accuracy of the formulation of TCM prescriptions, the proficiency of manipulation, and the ability to evaluate the therapeutic effect. In the western medicine skill operation test station, the main points of scoring included the standardization of operation, the strength of the concept of sterility, and the ability to deal with emergencies. In the case analysis and examination station, the scoring points included the accuracy of diagnosis, the rationality of treatment plan, and the ability to apply the concept of integrative Chinese and Western medicine treatment. Communication ability scoring is mainly evaluated from such aspects as language expression clarity, attitude affinity, and communication skill application. Students need clear and concise language expressions when communicating with patients, and avoid using too professional terms, so that patients can understand. The attitude should be affable, respect the privacy and feelings of patients, and show good professional quality. In terms of communication skills, patients should be good at listening to their demands, guide patients to accurately express their illness, and give patients appropriate comfort and encouragement. For example, in the history collection and examination station, students can patiently listen to the patient's story, guide the patient to supplement key information with mild language, and give the patient appropriate feedback in communication, such as nodding and expressing understanding, which can be reflected in the communication ability score. (5) feedback and summary After the examination, the examiners gave detailed feedback on the performance of GP in each examination station, pointed out its advantages and disadvantages, and gave targeted suggestions and guidance. At the same time, physicians were organized to undergo summary and reflection to help them recognize the weaknesses in their clinical skills and knowledge, and identify the direction of improvement. 3 Observation indicators 3.1 Assessment results of two groups of trainees after training. Out of the department assessment including theoretical knowledge, skills, operation, case analysis. 3.1.1 basic theory assessment form for the closed book written examination, including: (1) Multiple-choice traditional Chinese medicine: etiology and pathogenesis of anorectal diseases (downward flow of damp-heat, qi stagnation and blood stasis, spleen deficiency and qi stagnation, etc.); Western medicine: modern diagnosis and treatment specification for anorectal anatomy and common diseases (hemorrhoid, anal fissure and anal fistula). (2) Short answer questions: Application of classical prescriptions in traditional Chinese medicine (such as composition and indications of Zhitong Rushen Decoction, Huaijiao Pill and Buzhong Yiqi Decoction), and principle of external therapy in traditional Chinese medicine (operating points of fumigating, washing and hanging line therapies). (3) Syndrome differentiation analysis questions: According to the description of tongue and pulse, and symptoms, the syndrome type, therapeutic principle, and prescription were written. 3.1.2 skills operation assessment form for the field operation + oral points, content includes: (1) Acupuncture at acupoints for the treatment of anorectal diseases (demonstration of acupuncture manipulation and explanation of the basis for acupoint selection) (2) postoperative dressing (briefly describe the steps and choose prescription) (3) Anal visual examination, finger diagnosis, and anoscopy (oral examination results) 3.1.3 Case analysis and assessment form: real cases (including four diagnosis information and examination report) were extracted, and written analysis + examination points for on-site reply were provided. (1) TCM syndrome differentiation:. Syndrome elements (such as damp-heat, blood stasis and qi deficiency) were extracted from the chief complaint, tongue and pulse, and constitution. It should be distinguished from similar syndromes (for example, downward invasion of damp-heat syndrome vs deficiency of spleen and qi stagnation syndrome) (2) Treatment plan. Internal treatment in traditional Chinese medicine: addition and subtraction of classical prescriptions (indicating the drug dose and decocting and dosing method); External therapy in traditional Chinese medicine: combined application of fumigation and washing, acupuncture and moxibustion, and application; Western Medicine Coordination: Surgical Indications and Main Points of Postoperative Management (3) Reply link: answer the questions raised by the examiner (for example, "Why did you choose the thread-drawing therapy instead of direct incision?") 3.2 Teaching satisfaction/Clinical thinking ability After the teaching, the self-made teaching satisfaction questionnaire was used to investigate the teachers in the two groups. The content of the scale includes the evaluation of four items including teaching method, teaching content, teaching effect, and teachers' teaching level. The scale was divided into 5 grades: very dissatisfied, dissatisfied, not necessarily, satisfied and very satisfied. The teaching satisfaction scores of discipline physicians in the two groups were calculated and compared. The clinical thinking ability scale was used to evaluate the two groups of discipline physicians, and the instructor was responsible for scoring. The scale included problem analysis, diagnostic reasoning, treatment decision making, and condition assessment. The scale was divided into five levels: completely non-compliant, non-compliant, not necessarily, compliant and completely compliant. The assessment was conducted before and after teaching to compare the changes in clinical thinking ability of physicians in the two groups. The questionnaire was specifically developed for the present study; no previously validated version exists.(see Supplementary File for the English version) 4 Data analysis method All data were analyzed by SPSS 22.0 statistical analysis software, and the measurement data were expressed by (‾ X ± s ) and t-test. The counting data was represented by n, and the difference was statistically significant by x 2 test, P < 0.05. 5 Results 5.1 Comparison of assessment results of trainees between the two groups after training The experimental group's basic theoretical scores, skill operation and case analysis scores were higher than those of the control group, and the difference was statistically significant (P < 0.05), as shown in Table 3 . Table 3 Comparison of assessment results of trainees between the two groups after training (‾ X ± s , full scores of 100)‾X ± s, full marks 100分) group Theoretical achievements (points) Skill operation (points) Case analysis (score) Test group (n = 30) 89.5 ± 4.2 91.3 ± 3.8 93.2 ± 2.9 Control group (n = 30) 82.1 ± 5.6 85.4 ± 4.5 87.6 ± 3.7 T value 5.872 5.431 6.213 P value < 0.001 < 0.001 < 0.001 5.2 Comparison of teaching satisfaction between the two groups of students A total of 60 questionnaires were distributed in this study, and 60 were collected, with the effective recovery rate of 100%. The results showed that the experimental group's teaching satisfaction in teaching method, teaching content, teaching effect and teachers' teaching level was higher than that of the observation group and the differences were statistically significant (P < 0.05). See Table 4 . Table 4 Comparison of teaching satisfaction questionnaire results between the two groups Evaluation dimension opinion rating Number of experimental groups Number of observation groups Chi-square test results teaching method Very satisfied 12 2 χ²=19.31, p = 0.0007 be satisfied 10 4 Not necessarily/maybe 5 8 Dissatisfied 2 10 Very dissatisfied 1 6 content of courses Very satisfied 10 3 χ²=15.22, p = 0.0043 be satisfied 13 5 Not necessarily/maybe 4 8 Dissatisfied 2 9 Very dissatisfied 1 5 Teaching effect Very satisfied 9 2 χ²=14.85, p = 0.0051 be satisfied 14 6 Not necessarily/maybe 4 10 Dissatisfied 2 8 Very dissatisfied 1 4 Teachers' teaching level Very satisfied 11 3 χ²=13.89, p = 0.0078 be satisfied 12 7 Not necessarily/maybe 5 8 Dissatisfied 1 7 Very dissatisfied 1 5 5.3 Comparison of clinical thinking abilities of students in two groups before and after teaching, both within and between groups Before teaching, there was no significant difference in all dimensions between the two groups (p > 0.05). After teaching, the proportion of teachers' positive evaluation (coincidence/complete coincidence) in the experimental group was significantly higher than that in the control group and the difference was statistically significant (P < 0.05), as shown in Table 5 . Table 5 Comparison of clinical thinking ability of students in two groups before and after teaching, both within and between groups Evaluation dimension point of time opinion rating Number of experimental groups Number of observation groups Statistical test results (within/between groups) problem analysis Pre-teaching Not at all 8 7 Comparison within the experimental group before and after treatment: χ²=34.12, p < 0.001 inconformity 10 11 Comparison within the same group before and after treatment: χ²=5.23, p = 0.265 Not necessarily/maybe 9 8 Inter-group comparison before teaching: χ²=1.02, p = 0.906 accord with 2 3 Inter-group comparison after teaching: χ²=18.24, p = 0.001 be absolutely in accordance with 1 1 After teaching Not at all 2 6 inconformity 3 9 Not necessarily/maybe 5 8 accord with 12 5 be absolutely in accordance with 8 2 2 diagnostic reasoning Pre-teaching Not at all 7 6 Comparison within the experimental group before and after treatment: χ²=29.85, p < 0.001 inconformity 12 13 Comparison within the same group before and after treatment: χ²=4.17, p = 0.382 Not necessarily/maybe 7 8 Inter-group comparison before teaching: χ²=0.89, p = 0.925 accord with 3 2 Inter-group comparison after teaching: χ²=15.37, p = 0.004 be absolutely in accordance with 1 1 After teaching Not at all 1 5 inconformity 4 10 Not necessarily/maybe 6 9 accord with 11 4 be absolutely in accordance with 8 2 Treatment decisions Pre-teaching Not at all 9 8 Comparison within the experimental group before and after treatment: χ²=27.41, p < 0.001 inconformity 11 12 Comparison within the same group before and after treatment: χ²=3.85, p = 0.426 Not necessarily/maybe 7 7 Comparison between groups before teaching: χ²=0.76, p = 0.943 accord with 2 2 Inter-group comparison after teaching: χ²=16.83, p = 0.002 be absolutely in accordance with 1 1 After teaching Not at all 3 7 inconformity 5 10 Not necessarily/maybe 6 8 accord with 10 4 be absolutely in accordance with 6 1 Condition assessment Pre-teaching Not at all 10 9 Comparison within the experimental group before and after treatment: χ²=31.06, p < 0.001 inconformity 12 13 Comparison within the same group before and after treatment: χ²=4.92, p = 0.295 Not necessarily/maybe 6 6 Inter-group comparison before teaching: χ²=0.54, p = 0.968 accord with 1 1 Inter-group comparison after teaching: χ²=14.95, p = 0.005 be absolutely in accordance with 1 1 After teaching Not at all 2 8 inconformity 4 9 Not necessarily/maybe 7 7 accord with 11 5 be absolutely in accordance with 6 1 6 Result discussion and analysis 6.1 The advantages of CBL combined with OSCE teaching mode The control group adopted the traditional teaching mode, mainly focused on teachers' instruction. According to the requirements of the syllabus, the teachers systematically explain the theoretical knowledge of TCM anorectal science, including the etiology, pathology, clinical manifestations, diagnosis and treatment principles of the disease. In the process of explanation, some simple cases were combined for analysis, but the students' active participation and in-depth discussion were lacked. [ 5 ] . Clinical practice teaching was mainly carried out by the way of ward rounds and operation observation with the teacher leading the students. the students were mainly passive observation and learning in practice, and lacked the opportunity to think independently and solve problems [ 6 ] . The results of this study showed that the CBL combined with OSCE teaching model had significant advantages in the teaching of TCM anorectal planning and training physicians. In terms of improving students' clinical ability, the teaching model enables students to exercise their clinical thinking ability and problem-solving ability in the simulated clinical situations through the analysis and discussion of real cases. When facing the actual cases, students need to comprehensively use the theoretical knowledge learned to analyze the condition and put forward the diagnosis and treatment plan, which makes their clinical ability has been effectively improved. In the links of history collection and case analysis, students can grasp the patient's condition more accurately and put forward reasonable diagnosis and treatment suggestions. This teaching mode can also greatly stimulate students' interest in learning. The traditional teaching mode is based on the teacher's teaching, students are in a passive state of accepting knowledge, easily feel boring [ 7 ] . However, the CBL-OSCE teaching model is student-centered, which enables students to actively participate in the teaching process in autonomous learning and group discussions, thus increasing the interest and challenge of learning. Students in the process of solving practical problems, can feel their own progress and growth, thus stimulating the enthusiasm and initiative of learning. In the cultivation of team spirit, the group discussion in CBL teaching provides a good platform for students. The students communicate and cooperate with each other in groups to discuss case solutions, which not only improves their communication ability but also cultivates team spirit [ 8 ] . In the face of complex clinical cases, students can work together to give full play to their respective advantages and solve problems together. 6.2 Existing problems and challenges Although CBL combined with OSCE teaching model has many advantages, but in the actual application there are still some problems and challenges. The great demand of teaching resources is an obvious problem. CBL teaching needs a large number of real cases as teaching material, and needs to carefully organize and write these cases, which requires teachers to invest a lot of time and energy [ 9 ] . OSCE assessment needs to set up more than one test station, equipped with the corresponding equipment and the examiner, which also puts forward higher requirements for teaching resources [ 10 ] . The difficulty in changing teachers' roles is also a problem that needs to be overcome. In the traditional teaching mode, the teacher is the knowledge giver, while in the CBL combined with OSCE teaching mode, the teacher needs to be changed into a leader and an elicitor, which puts forward higher requirements for the teacher's teaching ability and professional accomplishment [ 11 ] . Some teachers may be difficult to adapt to this role change, in the teaching process is still using the traditional teaching methods, affecting the teaching effect. The degree of assessment standardization needs to be improved. Although there is a clear scoring standard in OSCE assessment, in actual operation, the differences of assessment results may be caused by the subjective factors of the examiners and the assessment environment. Need to further improve the assessment criteria, strengthen the training of the examiner, improve the degree of standardization of assessment [ 12 ] . 6.3 improvement measures and suggestions (1) optimizing case design At present, the cases added to the CBL case database are mainly the basic diseases required by the rotation plan, which can be upgraded and enriched in the future, such as the addition of difficult cases [ 13 ] . At the same time, it is enlightening and challenging to strengthen the training of case writing, improve the ability of teachers to write high-quality cases, and ensure that cases can accurately reflect the actual clinical situation. (2) strengthening teacher training Organize teachers to participate in relevant teaching training courses, learn the concepts, methods and skills of CBL and OSCE teaching mode, and improve teachers' teaching ability and professional quality [ 14 ] . Encourage exchanges and cooperation between teachers, share teaching experience, and jointly improve the quality of teaching. (3) improve the assessment system Further refine the scoring criteria for OSCE assessment, and clarify the specific requirements and scoring rules of each assessment point. Strengthen the training of examiners, unify the scoring scale of examiners, and reduce the influence of subjective factors on the examination results. At the same time, the introduction of diversified assessment methods, such as student self-assessment, mutual evaluation, improve the comprehensive and objective assessment [ 15 ] . 7 Conclusion and prospect 7.1 Study Summary In this study, CBL combined with OSCE was applied in the teaching of traditional Chinese medicine (TCM) anorectal planning and training. Through the careful design of teaching cases and OSCE examination station, the comprehensive ability of students was comprehensively trained and assessed. The results have shown that the CBL combined with OSCE teaching model can significantly improve the learning effect and clinical ability of TCM anorectal planners. In terms of theoretical knowledge assessment, the scores of students in the experimental group were significantly better than those in the control group, indicating that this teaching mode helped students to better master the theoretical knowledge of TCM anorectal subject. In the practical skills examination, the students in the experimental group performed better in medical history collection, physical examination, Chinese medicine skill operation and western medicine skill operation, indicating that the students' practical ability was effectively improved. In addition, students have a high degree of satisfaction with the CBL combined with OSCE teaching model, believing that the model can stimulate learning interest, improve learning enthusiasm, and cultivate the ability to solve practical problems and team spirit. The CBL combined with OSCE teaching model has important application value and feasibility in the teaching of TCM anorectal planning and training physicians. Through the analysis and discussion of real cases, students can combine theoretical knowledge with clinical practice closely to improve clinical thinking ability and problem-solving ability. On the other hand, OSCE's comprehensive assessment can timely identify students' shortcomings and provide the basis for teaching improvement. Therefore, the teaching model is worthy of further promotion and application in the teaching of TCM anorectal planning and training, in order to cultivate more high-quality TCM anorectal professionals. 7.2 Research Deficiencies and Prospects Although some results have been achieved in this study, there are still some shortcomings. Although the baseline of the two groups was balanced, the past clinical experience of the trainees was not controlled, which may influence the results and further covariate analysis needs to be included in the future. The relatively small sample size (n = 60) may affect the universality and reliability of the research results. As a result, subsequent studies can include multi-center large sample verification, covering more TCM anorectal planners, in order to improve the credibility of the research results. The research time is short, and it is difficult to evaluate the long-term effect with the two-month training cycle. There is lack of in-depth tracking and evaluation of the long-term effect of CBL combined with OSCE teaching model. The follow-up study can carry out long-term follow-up investigation to observe the students' performance in clinical work after graduation, so as to comprehensively evaluate the impact of the teaching mode on the professional development of students [ 16 ] . In addition, in the selection and design of teaching cases, although the common TCM anorectal diseases have been covered as far as possible, the cases involving some rare and difficult diseases are less. In the future, we can further enrich the case database and add cases of rare and difficult diseases to broaden students' knowledge and clinical thinking [ 17 ] . At the same time, the setting of OSCE examination station and the establishment of scoring criteria can be further optimized and improved to more scientifically, reasonably and objectively reflect the clinical ability of students [ 18 ] . In the future research, we can also explore the integration of CBL combined with OSCE teaching mode and other teaching methods, such as problem-based learning (PBL), simulation teaching, to further improve the teaching effect [ 19 ] . At the same time, with the continuous development of information technology, online teaching resources can also be combined with offline teaching to carry out hybrid teaching, to provide more rich and diverse learning experience for students [ 20 ] . Declarations Ethics approval and consent to participate All methods were carried out in accordance with the Helsinki Declaration. All subjects obtained informed consent orally, and the investigation was anonymous and voluntary, which was approved by the Ethics Committee of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine. The Ethics Committee of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine gave up the need for ethical examination and approval. Consent for publication Not applicable. Data availability All data generated or analysed during this study are included in this publishedarticle. Competing interests The authors declare no competing interests. Funding This research was supported by the Cultivation Project of Henan University of Traditional Chinese Medicine, with the project number as 242301420114. Authors' contributions Li carried out experiments and wrote papers, and collected and analyzed the data. Zhang designed the experiment, revised the paper and supervised the work. All the authors participated in the design of the questionnaire, read and approved the final draft. Acknowledgements The authors wishes to thank Henan University of Traditional Chinese Medicine for providing funds to support this research. Clinical trial number Not applicable. 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Guo J, Dong LYW. Peng Meiyu Preliminary exploration of the application of RBL combined with PBL teaching mode in medical immunology teaching [J]. Chin J Immunol. 2022;38(17):2136–9. Zhang, Min. Guo Shengbin Exploration and Research on the Teaching Reform of Pathogenic Biology in Oral Medicine Major Guided by Clinical Thinking [J]. Chin J Pathogenic Biology. 2025;20(05):687–90. Wang, Ming. Wu Chuyan Application of Clinical Teaching Based on the Recommended Guidelines for Clinical Treatment of Scar Scars in China in Standardized Training for Resident Physicians in Plastic and Burn Surgery and Rehabilitation Departments [J]. Chin J Rehabilitation Med. 2024;39(09):1369–70. Zhao Xiaohui W, Bao Y, Yonghe. Li Xuejiao, Xie Yongsheng Comparative Study on the Application and Effectiveness of PBL and CBL Teaching Methods in Pathogenic Biology Teaching [J]. Chin J Pathogenic Biology. 2025;20(03):408–11. Zhang, Xintong. Zheng Yu Application of bedside team teaching method combined with case-based teaching method in severe cardiopulmonary rehabilitation teaching [J]. Chin J Rehabilitation Med. 2023;38(10):1429–31. Dong Wenjing Z, Qian Z, Ruifang L, Xiaole C, Gege. Duan Xuan, Han Shifan Construction of Core Belief Professional Behavior Framework for Advanced Practice Nurses in China [J]. Nurs Res. 2025;39(02):183–96. Jingwen H. Xu Jiali Research on the Application of CBL Teaching Method in Clinical Internship Course of Diagnosis [J]. Chinese University Teaching; 2021. pp. 66–8. 03. Song Lan S, Hao Z, Daming X, Huadan C, Xuan YW, Wei S. Jin Zhengyu Application of Objective Structured Clinical Examination in Standardized Training Graduation Examination for Resident Physicians [J]. J Chin Acad Med Sci. 2021;43(06):922–4. Zhang Mingjun J, Xuan G, Xiaojuan G, Weibing. Zhou Jin Clinical Digestive Medicine Teaching Reform Based on CBL and Experiential Teaching Concept [J]. 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Song Shaojie Research on the Standardized Training and Teaching Mode and Application Effect of General Practitioners in China [J]. Chin J Gen Pract. 2021;24(19):2401–7. Liu Yushu W, Dong Z, Guifang YS, Wei Z. Yao Tianling Analysis of the application effect of blended learning combined with the 5E teaching mode in general residency training teaching [J]. China Hosp Manage. 2023;43(05):85–7. Additional Declarations No competing interests reported. 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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-7287583","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":514837342,"identity":"d2bc377f-fd4b-4201-9221-a7c2e66037b0","order_by":0,"name":"Linhui Li","email":"","orcid":"","institution":"The First Affiliated Hospital of Henan University of Chinese Medicine","correspondingAuthor":false,"prefix":"","firstName":"Linhui","middleName":"","lastName":"Li","suffix":""},{"id":514837343,"identity":"3834786a-0eed-4024-b503-c2543bdb7cc4","order_by":1,"name":"Shuangxi Zhang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAqUlEQVRIiWNgGAWjYHACZhAhx8befIA0LcZ8PMcSSNOSOE8iR4E49QbHex8b/vhzOL2NIYeB4UfFNiK0nDlunCDZlpbbxnD2AGPPmduEtZjdSGM+YNhgk9vG2JfAzNhGrJaEPxLpbMw8BsRrSTjAZpPAxkasFvszx5gNG9vSDNt42BIOEuUXyfY2ZklgiMnLz3988MGPCiK0oIADJKofBaNgFIyCUYALAAAgjThsyvIbeQAAAABJRU5ErkJggg==","orcid":"","institution":"The First Affiliated Hospital of Henan University of Chinese Medicine","correspondingAuthor":true,"prefix":"","firstName":"Shuangxi","middleName":"","lastName":"Zhang","suffix":""}],"badges":[],"createdAt":"2025-08-04 06:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7287583/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7287583/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":91657155,"identity":"1a4d1ba1-4c1d-469d-804f-c2825afa5950","added_by":"auto","created_at":"2025-09-18 18:28:49","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1485046,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7287583/v1/864f056a-5cad-4e85-a42c-ecfd8aa41e51.pdf"},{"id":91656481,"identity":"faefb774-9d37-471c-95ab-6687f8539c78","added_by":"auto","created_at":"2025-09-18 18:12:48","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":15303,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile.docx","url":"https://assets-eu.researchsquare.com/files/rs-7287583/v1/e876a5253efcecf92f8fa27b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Research on the Application of CBL Combined with OSCE in the Teaching of Anorectal Standardized Training Physician of Traditional Chinese Medicine","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAnorectal science of traditional Chinese medicine (TCM), as a special branch of TCM, has a long history and rich clinical experience in China. With the development of modern medicine, the demand for TCM anorectal professionals is growing, and the importance of TCM anorectal training teaching has become increasingly prominent. Standardized resident training is an important part of post-graduate education for medical students and an effective way to cultivate excellent clinicians\u003csup\u003e[1]\u003c/sup\u003e. However, the current planning and training teaching is still dominated by teachers, students passively accept knowledge, the lack of clinical thinking training, and assessment depends on theoretical written examination, focusing on theoretical memory, ignoring the evaluation of practical ability and communication skills, TCM characteristic diagnosis and treatment and the integration of modern technology teaching case is less, it is difficult to fully assess the practical ability of students\u003csup\u003e[2]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eCase-Based Learning (CBL) is based on real cases, and guides students to solve practical problems through analysis and discussion. it can improve students\u0026apos; learning interest and initiative, and cultivate students\u0026apos; clinical thinking ability and problem-solving ability\u003csup\u003e[3]\u003c/sup\u003e. Objective structured clinical examination (OSCE) is an objective and comprehensive assessment model. it can effectively evaluate the clinical ability of students by setting up multiple examination stations, simulating the actual clinical scenarios, and comprehensively assessing their clinical skills, communication ability, and professional quality\u003csup\u003e[4]\u003c/sup\u003e. In recent years, CBL and OSCE have been gradually promoted in medical education, but their application in the field of traditional Chinese medicine (TCM) anorectal still lacks high-quality research. In this study, the two were innovatively combined, and the case and assessment site was designed according to the characteristics of diagnosis and treatment of integrated Chinese and Western medicine in anorectal department. The purpose of the study was to give full play to the advantages of the two, improve the quality of teaching, explore the optimal path suitable for the teaching of integrated Chinese and Western medicine, and cultivate Chinese anorectal professionals with a solid theoretical basis, skilled clinical skills and good professional quality. This not only fills the gap in the teaching mode of TCM anorectal field, helps to improve the overall level of TCM anorectal subject, but also better meets the needs of patients for high quality medical service, which has important practical significance.\u003c/p\u003e"},{"header":"1 Study Object","content":"\u003cp\u003eSixty residents who received standardized resident training in the Department of Coloproctology and Gastroenterology, the First Affiliated Hospital of Henan University of Chinese Medicine from June 2023 to December 2024 were selected as the research subjects in this study. All residents participated in standardized training for residents in Henan Province, and the training period in the Coloproctology Department was two months.\u003c/p\u003e\u003cp\u003eInclusion criteria: voluntary participation in the study; Standardized training for anorectal specialty in traditional Chinese medicine is being conducted; Have certain basic medical knowledge. Exclusion criteria were: physicians who dropped out of the training or were unable to complete the entire study due to special reasons. This study was approved by the Ethics Committee of Henan University of Traditional Chinese Medicine and the case data were desensitized.\u003c/p\u003e\u003cp\u003eSPSS 22.0 was used to generate a random sequence, and independent researchers assigned the subjects to groups. The teachers and students were unaware of the grouping (single-blind method). The subjects were divided into an experimental group (CBL\u0026thinsp;+\u0026thinsp;OSCE) and a control group (traditional teaching), 30 in each group. The balance test of the two groups of discipline physicians in age, gender, and enrollment performance showed no statistically significant difference (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05), with comparability. See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\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\u003cp\u003eComparison of general conditions between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003egroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber of cases\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge (years,\u0026oline;X\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGender (male/female)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBasic scores (score,\u0026oline;X\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003econtrol group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15/15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExperimental group\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14/16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e76.2\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT/χ2 value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eχ\u0026sup2;=0.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003et\u0026thinsp;=\u0026thinsp;0.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.537\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.604\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.663\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003eNote: the differences were not statistically significant (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"2 Teaching methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 control group (traditional teaching group)\u003c/h2\u003e\u003cp\u003eAccording to the Management Methods of Standardized Training for Resident Doctors in Henan Province, during the standardized training of resident doctors in our department, a learning seminar related to basic clinical knowledge and skills was held once a week in the department. The clinical teaching teachers used PPT to teach, and focused on explaining the pathogenesis, pathophysiology, clinical manifestations, diagnosis and differential diagnosis, treatment and prognosis of common anorectal diseases to the planning and training physicians according to the requirements of the teaching syllabus. At the same time, practical operation skills were trained.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Test group (CBL\u0026thinsp;+\u0026thinsp;OSCE group)\u003c/h2\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 CBL teaching implementation\u003c/h2\u003e\u003cp\u003e(1) Case selection. The instructor selected the patients of typical cases (mixed hemorrhoids, anal fissure, anal fistula, and perianal abscess) in the Coloproctology Department of our hospital as the object of case discussion, and distributed the materials to the students in advance, so that the students could consult the materials before class to further understand the disease, and proposed the common clinical problems.\u003c/p\u003e\u003cp\u003e(2) Question posing: The teacher guided the students to comprehensively collect medical records and physical examination information, and put forward positioning diagnosis and qualitative diagnosis problems, including disease type, staging and cause, through imaging reading and analysis, whether further examination was needed.\u003c/p\u003e\u003cp\u003e(3) Problem analysis: Combined with the actual cases, in view of the proposed problems, the teachers organized the students to discuss in groups, and conducted a comprehensive analysis of the case history, physical examination and auxiliary examination data, in order to correct the wrong understanding in the discussion among the students in time and formulate the correct diagnosis and treatment plan. At the same time, in response to the questions raised by the students, the teacher should guide them to think independently, such as applying the knowledge learned to analyze the problems, or consulting the answers to the problems with the help of the literature and the network, so as to give full guidance to the teacher, rather than directly answering the questions.\u003c/p\u003e\u003cp\u003e(4) Summary: After the group discussion, the teacher should systematically and retrospectively analyze and explain the relevant cases, summarize the discussion topics, correct the wrong views of the students, give a detailed lecture on the definition, type, etiology and standardized diagnosis of anorectal diseases, and introduce some international cutting-edge theories and technologies related to anorectal medicine to the students.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2 Implementation of OSCE assessment\u003c/h2\u003e\u003cp\u003e(1) personnel organization\u003c/p\u003e\u003cp\u003eBefore the assessment, the establishment of a special assessment of the leading group, responsible for the organization of the examiner training, the development of assessment programs, coordination of assessment sites and materials and other work. The examiner shall be the attending physician or deputy director physician with rich clinical experience and teaching experience, and conduct unified training before the examination, so as to ensure that the examiner is familiar with the examination procedures, scoring standards and requirements, and ensure the fairness and accuracy of the examination. The interexaminer consistency test in the preliminary experiment showed that the Kappa coefficient was 0.85(P\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e\u003cp\u003e(2) site settings\u003c/p\u003e\u003cp\u003eAfter the examinee enters the examination hall, first carries on the identity authentication, after the confirmation examinee information is correct, guides the examinee to enter the waiting examination area. Waiting area set up a special staff, responsible for maintaining order, to introduce candidates assessment process and matters needing attention. According to the order of drawing lots, the examinees enter each test station in turn for examination.\u003c/p\u003e\u003cp\u003eFive standardized test stations were set up to simulate the real clinical scenarios. The assessment time for each test station was 15 minutes, and the candidates completed the corresponding assessment tasks within the prescribed time. Professional ability accounted for 80% (operational accuracy and standardization), and communication ability accounted for 20% (language expression and patient interaction). See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e:\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eOSCE site settings\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003estation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssessment content\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ecore competence\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eScoring criteria (100 points)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. History collection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSimulating a visiting scene of a mixed hemorrhoid/anal fissure patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInterrogation techniques\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eInterrogation integrity\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. Physical examination\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnoscopy, digital rectal examination, anoscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSpecialty physical examination standardization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePhysical examination standardization\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. TCM skills operation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChinese medicine fumigating and washing, acupuncture and moxibustion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCharacteristic treatment skills of traditional chinese medicine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSquare-certificate fit degree\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. western medicine skills operation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDebridement, suture and dressing change\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBasic operation of western medicine surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOperational proficiency\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Comprehensive case analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplex case (high complex anal fistula complicated with diabetes mellitus)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMultidisciplinary diagnosis and treatment thinking, individual treatment plan\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProgramme comprehensiveness\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: special rule: in site 5, 10 points will be deducted if participants fail to voluntarily mention multi-disciplinary diagnosis and treatment.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e(3)OSCE implementation\u003c/p\u003e\u003cp\u003eFirst stop: history taking\u003c/p\u003e\u003cp\u003eIt mainly examines the students' ability to communicate with patients and obtain accurate medical history information. Students need to accurately understand the patient's condition within the stipulated time by asking questions about the patient's symptoms, onset time, past medical history, and family medical history. For example, in the face of a patient with hematochezia, students need to ask in detail the color, quantity and frequency of hematochezia, whether there are accompanied by symptoms such as pain and prolapse, as well as the patient's eating habits, daily life and rest, and so on and so forth, to provide the basis for the subsequent diagnosis and treatment.\u003c/p\u003e\u003cp\u003eSecond stop: physical examination\u003c/p\u003e\u003cp\u003eStudents are required to be familiar with the methods and skills of physical examination in TCM anorectal specialty. Students need to conduct anoscopy, digital rectal examination, and anoscopy to accurately judge the patient's condition. When inspecting the anus, observe whether there is any mass, fissure, swelling, secretion, etc. around the anus; Rectal digital diagnosis, feel the hardness of the rectal wall, the presence of masses, tenderness, stenosis, etc.; During anoscopy, the anal canal and rectal mucosa are observed, including internal hemorrhoid, ulcer and hemorrhage.\u003c/p\u003e\u003cp\u003eThird stop: TCM skill manipulation\u003c/p\u003e\u003cp\u003eFocus on the students' traditional Chinese medicine treatment skills. Including Chinese medicine fumigation, Chinese medicine sitz bath, acupuncture, massage, etc. Taking Chinese medicine fumigation as an example, students need to accurately formulate Chinese medicine prescriptions according to the patient's condition, and master the temperature, time and method of fumigation to ensure the therapeutic effect. In acupuncture manipulation, students should be familiar with the positioning of acupoints, the angle and depth of insertion of acupuncture, and the manipulation of acupuncture.\u003c/p\u003e\u003cp\u003eFourth stop: western medicine skill operation\u003c/p\u003e\u003cp\u003eIt mainly inspects students' basic operation skills of western medicine surgery. In debridement and suture, students need to correctly handle the wound, disinfection, hemostasis, suture and other operations to ensure good wound healing. Dressing change, should strictly abide by the principle of aseptic operation, correct change dressings, observe the wound healing.\u003c/p\u003e\u003cp\u003eStation 5: case analysis\u003c/p\u003e\u003cp\u003eStudents are required to comprehensively use the knowledge learned to analyze and diagnose a given case and propose a reasonable treatment. Students need to conduct TCM syndrome differentiation and western medicine diagnosis according to the information of medical history, physical examination, auxiliary examination and so on, to develop a treatment plan of TCM and western medicine. For patients with high complex anal fistula complicated with diabetes, students need to analyze the etiology and pathogenesis from the perspective of traditional Chinese medicine (TCM) to determine the syndrome type, and adopt the methods of oral administration and external application of TCM to treat it. At the same time, the type and degree of anal fistula were clarified from the perspective of western medicine, and the appropriate surgical method was selected for treatment.\u003c/p\u003e\u003cp\u003e(4)OSCE score\u003c/p\u003e\u003cp\u003eThe scoring of each test station includes two aspects: professional ability and communication ability. The professional ability scoring is mainly based on the students' operation accuracy, standardization, proficiency as well as the mastery and application ability of knowledge in the test station. At the medical history collection and examination station, the key points of professional ability scoring include the comprehensiveness and accuracy of asking the medical history, the ability to grasp key information, and whether the preliminary condition analysis can be conducted according to the medical history. In the physical examination station, the main points of scoring include the correctness of the examination method, the standardization of operation, and the accurate judgment ability of physical signs. In the TCM skill manipulation test station, the scoring points included the accuracy of the formulation of TCM prescriptions, the proficiency of manipulation, and the ability to evaluate the therapeutic effect. In the western medicine skill operation test station, the main points of scoring included the standardization of operation, the strength of the concept of sterility, and the ability to deal with emergencies. In the case analysis and examination station, the scoring points included the accuracy of diagnosis, the rationality of treatment plan, and the ability to apply the concept of integrative Chinese and Western medicine treatment.\u003c/p\u003e\u003cp\u003eCommunication ability scoring is mainly evaluated from such aspects as language expression clarity, attitude affinity, and communication skill application. Students need clear and concise language expressions when communicating with patients, and avoid using too professional terms, so that patients can understand. The attitude should be affable, respect the privacy and feelings of patients, and show good professional quality. In terms of communication skills, patients should be good at listening to their demands, guide patients to accurately express their illness, and give patients appropriate comfort and encouragement. For example, in the history collection and examination station, students can patiently listen to the patient's story, guide the patient to supplement key information with mild language, and give the patient appropriate feedback in communication, such as nodding and expressing understanding, which can be reflected in the communication ability score.\u003c/p\u003e\u003cp\u003e(5) feedback and summary\u003c/p\u003e\u003cp\u003eAfter the examination, the examiners gave detailed feedback on the performance of GP in each examination station, pointed out its advantages and disadvantages, and gave targeted suggestions and guidance. At the same time, physicians were organized to undergo summary and reflection to help them recognize the weaknesses in their clinical skills and knowledge, and identify the direction of improvement.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"3 Observation indicators","content":"\u003cp\u003e3.1 Assessment results of two groups of trainees after training. Out of the department assessment including theoretical knowledge, skills, operation, case analysis.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003cdiv class=\"Heading\"\u003e3.1.1 basic theory assessment form for the closed book written examination, including:\u003c/div\u003e\u003cp\u003e(1) Multiple-choice traditional Chinese medicine: etiology and pathogenesis of anorectal diseases (downward flow of damp-heat, qi stagnation and blood stasis, spleen deficiency and qi stagnation, etc.); Western medicine: modern diagnosis and treatment specification for anorectal anatomy and common diseases (hemorrhoid, anal fissure and anal fistula).\u003c/p\u003e\u003cp\u003e(2) Short answer questions: Application of classical prescriptions in traditional Chinese medicine (such as composition and indications of Zhitong Rushen Decoction, Huaijiao Pill and Buzhong Yiqi Decoction), and principle of external therapy in traditional Chinese medicine (operating points of fumigating, washing and hanging line therapies).\u003c/p\u003e\u003cp\u003e(3) Syndrome differentiation analysis questions: According to the description of tongue and pulse, and symptoms, the syndrome type, therapeutic principle, and prescription were written.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003cdiv class=\"Heading\"\u003e3.1.2 skills operation assessment form for the field operation\u0026thinsp;+\u0026thinsp;oral points, content includes:\u003c/div\u003e\u003cp\u003e(1) Acupuncture at acupoints for the treatment of anorectal diseases (demonstration of acupuncture manipulation and explanation of the basis for acupoint selection)\u003c/p\u003e\u003cp\u003e(2) postoperative dressing (briefly describe the steps and choose prescription)\u003c/p\u003e\u003cp\u003e(3) Anal visual examination, finger diagnosis, and anoscopy (oral examination results)\u003c/p\u003e\u003cp\u003e 3.1.3 Case analysis and assessment form: real cases (including four diagnosis information and examination report) were extracted, and written analysis\u0026thinsp;+\u0026thinsp;examination points for on-site reply were provided.\u003c/p\u003e\u003cp\u003e(1) TCM syndrome differentiation:. Syndrome elements (such as damp-heat, blood stasis and qi deficiency) were extracted from the chief complaint, tongue and pulse, and constitution. It should be distinguished from similar syndromes (for example, downward invasion of damp-heat syndrome vs deficiency of spleen and qi stagnation syndrome)\u003c/p\u003e\u003cp\u003e(2) Treatment plan. Internal treatment in traditional Chinese medicine: addition and subtraction of classical prescriptions (indicating the drug dose and decocting and dosing method); External therapy in traditional Chinese medicine: combined application of fumigation and washing, acupuncture and moxibustion, and application; Western Medicine Coordination: Surgical Indications and Main Points of Postoperative Management\u003c/p\u003e\u003cp\u003e(3) Reply link: answer the questions raised by the examiner (for example, \"Why did you choose the thread-drawing therapy instead of direct incision?\")\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Teaching satisfaction/Clinical thinking ability\u003c/h2\u003e\u003cp\u003eAfter the teaching, the self-made teaching satisfaction questionnaire was used to investigate the teachers in the two groups. The content of the scale includes the evaluation of four items including teaching method, teaching content, teaching effect, and teachers' teaching level. The scale was divided into 5 grades: very dissatisfied, dissatisfied, not necessarily, satisfied and very satisfied. The teaching satisfaction scores of discipline physicians in the two groups were calculated and compared.\u003c/p\u003e\u003cp\u003eThe clinical thinking ability scale was used to evaluate the two groups of discipline physicians, and the instructor was responsible for scoring. The scale included problem analysis, diagnostic reasoning, treatment decision making, and condition assessment. The scale was divided into five levels: completely non-compliant, non-compliant, not necessarily, compliant and completely compliant. The assessment was conducted before and after teaching to compare the changes in clinical thinking ability of physicians in the two groups.\u003c/p\u003e\u003cp\u003eThe questionnaire was specifically developed for the present study; no previously validated version exists.(see Supplementary File for the English version)\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Data analysis method","content":"\u003cp\u003eAll data were analyzed by SPSS 22.0 statistical analysis software, and the measurement data were expressed by (\u0026oline;\u003cb\u003eX\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/b\u003e) and t-test. The counting data was represented by n, and the difference was statistically significant by x\u003csup\u003e2\u003c/sup\u003e test, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"5 Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e5.1 Comparison of assessment results of trainees between the two groups after training\u003c/h2\u003e\u003cp\u003eThe experimental group's basic theoretical scores, skill operation and case analysis scores were higher than those of the control group, and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of assessment results of trainees between the two groups after training (\u0026oline;\u003cb\u003eX\u0026thinsp;\u0026plusmn;\u0026thinsp;s\u003c/b\u003e, full scores of 100)\u0026oline;X\u0026thinsp;\u0026plusmn;\u0026thinsp;s, full marks 100分)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003egroup\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTheoretical achievements (points)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSkill operation (points)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCase analysis (score)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTest group (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e89.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.3\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e93.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eControl group (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e85.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.872\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.431\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.213\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\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\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e5.2 Comparison of teaching satisfaction between the two groups of students\u003c/h2\u003e\u003cp\u003eA total of 60 questionnaires were distributed in this study, and 60 were collected, with the effective recovery rate of 100%. The results showed that the experimental group's teaching satisfaction in teaching method, teaching content, teaching effect and teachers' teaching level was higher than that of the observation group and the differences were statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). See Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of teaching satisfaction questionnaire results between the two groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluation dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eopinion rating\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNumber of experimental groups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber of observation groups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eChi-square test results\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eteaching method\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2;=19.31, p\u0026thinsp;=\u0026thinsp;0.0007\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebe satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003econtent of courses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2;=15.22, p\u0026thinsp;=\u0026thinsp;0.0043\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebe satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeaching effect\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2;=14.85, p\u0026thinsp;=\u0026thinsp;0.0051\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebe satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTeachers' teaching level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eχ\u0026sup2;=13.89, p\u0026thinsp;=\u0026thinsp;0.0078\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ebe satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003e5.3 Comparison of clinical thinking abilities of students in two groups before and after teaching, both within and between groups\u003c/b\u003e\u003c/p\u003e\u003cp\u003eBefore teaching, there was no significant difference in all dimensions between the two groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). After teaching, the proportion of teachers' positive evaluation (coincidence/complete coincidence) in the experimental group was significantly higher than that in the control group and the difference was statistically significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of clinical thinking ability of students in two groups before and after teaching, both within and between groups\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\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=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEvaluation dimension\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003epoint of time\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eopinion rating\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber of experimental groups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNumber of observation groups\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eStatistical test results (within/between groups)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eproblem analysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the experimental group before and after treatment: χ\u0026sup2;=34.12, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the same group before and after treatment: χ\u0026sup2;=5.23, p\u0026thinsp;=\u0026thinsp;0.265\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison before teaching: χ\u0026sup2;=1.02, p\u0026thinsp;=\u0026thinsp;0.906\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison after teaching: χ\u0026sup2;=18.24, p\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 diagnostic reasoning\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the experimental group before and after treatment: χ\u0026sup2;=29.85, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the same group before and after treatment: χ\u0026sup2;=4.17, p\u0026thinsp;=\u0026thinsp;0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison before teaching: χ\u0026sup2;=0.89, p\u0026thinsp;=\u0026thinsp;0.925\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison after teaching: χ\u0026sup2;=15.37, p\u0026thinsp;=\u0026thinsp;0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTreatment decisions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the experimental group before and after treatment: χ\u0026sup2;=27.41, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the same group before and after treatment: χ\u0026sup2;=3.85, p\u0026thinsp;=\u0026thinsp;0.426\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison between groups before teaching: χ\u0026sup2;=0.76, p\u0026thinsp;=\u0026thinsp;0.943\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison after teaching: χ\u0026sup2;=16.83, p\u0026thinsp;=\u0026thinsp;0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCondition assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the experimental group before and after treatment: χ\u0026sup2;=31.06, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eComparison within the same group before and after treatment: χ\u0026sup2;=4.92, p\u0026thinsp;=\u0026thinsp;0.295\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison before teaching: χ\u0026sup2;=0.54, p\u0026thinsp;=\u0026thinsp;0.968\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eInter-group comparison after teaching: χ\u0026sup2;=14.95, p\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAfter teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot at all\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003einconformity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot necessarily/maybe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eaccord with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ebe absolutely in accordance with\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"6 Result discussion and analysis","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e6.1 The advantages of CBL combined with OSCE teaching mode\u003c/h2\u003e\u003cp\u003eThe control group adopted the traditional teaching mode, mainly focused on teachers' instruction. According to the requirements of the syllabus, the teachers systematically explain the theoretical knowledge of TCM anorectal science, including the etiology, pathology, clinical manifestations, diagnosis and treatment principles of the disease. In the process of explanation, some simple cases were combined for analysis, but the students' active participation and in-depth discussion were lacked.\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e. Clinical practice teaching was mainly carried out by the way of ward rounds and operation observation with the teacher leading the students. the students were mainly passive observation and learning in practice, and lacked the opportunity to think independently and solve problems\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe results of this study showed that the CBL combined with OSCE teaching model had significant advantages in the teaching of TCM anorectal planning and training physicians. In terms of improving students' clinical ability, the teaching model enables students to exercise their clinical thinking ability and problem-solving ability in the simulated clinical situations through the analysis and discussion of real cases. When facing the actual cases, students need to comprehensively use the theoretical knowledge learned to analyze the condition and put forward the diagnosis and treatment plan, which makes their clinical ability has been effectively improved. In the links of history collection and case analysis, students can grasp the patient's condition more accurately and put forward reasonable diagnosis and treatment suggestions. This teaching mode can also greatly stimulate students' interest in learning. The traditional teaching mode is based on the teacher's teaching, students are in a passive state of accepting knowledge, easily feel boring\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. However, the CBL-OSCE teaching model is student-centered, which enables students to actively participate in the teaching process in autonomous learning and group discussions, thus increasing the interest and challenge of learning. Students in the process of solving practical problems, can feel their own progress and growth, thus stimulating the enthusiasm and initiative of learning. In the cultivation of team spirit, the group discussion in CBL teaching provides a good platform for students. The students communicate and cooperate with each other in groups to discuss case solutions, which not only improves their communication ability but also cultivates team spirit\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. In the face of complex clinical cases, students can work together to give full play to their respective advantages and solve problems together.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e6.2 Existing problems and challenges\u003c/h2\u003e\u003cp\u003eAlthough CBL combined with OSCE teaching model has many advantages, but in the actual application there are still some problems and challenges. The great demand of teaching resources is an obvious problem. CBL teaching needs a large number of real cases as teaching material, and needs to carefully organize and write these cases, which requires teachers to invest a lot of time and energy\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e. OSCE assessment needs to set up more than one test station, equipped with the corresponding equipment and the examiner, which also puts forward higher requirements for teaching resources\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe difficulty in changing teachers' roles is also a problem that needs to be overcome. In the traditional teaching mode, the teacher is the knowledge giver, while in the CBL combined with OSCE teaching mode, the teacher needs to be changed into a leader and an elicitor, which puts forward higher requirements for the teacher's teaching ability and professional accomplishment\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Some teachers may be difficult to adapt to this role change, in the teaching process is still using the traditional teaching methods, affecting the teaching effect.\u003c/p\u003e\u003cp\u003eThe degree of assessment standardization needs to be improved. Although there is a clear scoring standard in OSCE assessment, in actual operation, the differences of assessment results may be caused by the subjective factors of the examiners and the assessment environment. Need to further improve the assessment criteria, strengthen the training of the examiner, improve the degree of standardization of assessment\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e6.3 improvement measures and suggestions\u003c/h2\u003e\u003cp\u003e(1) optimizing case design\u003c/p\u003e\u003cp\u003eAt present, the cases added to the CBL case database are mainly the basic diseases required by the rotation plan, which can be upgraded and enriched in the future, such as the addition of difficult cases\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. At the same time, it is enlightening and challenging to strengthen the training of case writing, improve the ability of teachers to write high-quality cases, and ensure that cases can accurately reflect the actual clinical situation.\u003c/p\u003e\u003cp\u003e(2) strengthening teacher training\u003c/p\u003e\u003cp\u003eOrganize teachers to participate in relevant teaching training courses, learn the concepts, methods and skills of CBL and OSCE teaching mode, and improve teachers' teaching ability and professional quality\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. Encourage exchanges and cooperation between teachers, share teaching experience, and jointly improve the quality of teaching.\u003c/p\u003e\u003cp\u003e(3) improve the assessment system\u003c/p\u003e\u003cp\u003eFurther refine the scoring criteria for OSCE assessment, and clarify the specific requirements and scoring rules of each assessment point. Strengthen the training of examiners, unify the scoring scale of examiners, and reduce the influence of subjective factors on the examination results. At the same time, the introduction of diversified assessment methods, such as student self-assessment, mutual evaluation, improve the comprehensive and objective assessment\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"7 Conclusion and prospect","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e7.1 Study Summary\u003c/h2\u003e\u003cp\u003eIn this study, CBL combined with OSCE was applied in the teaching of traditional Chinese medicine (TCM) anorectal planning and training. Through the careful design of teaching cases and OSCE examination station, the comprehensive ability of students was comprehensively trained and assessed. The results have shown that the CBL combined with OSCE teaching model can significantly improve the learning effect and clinical ability of TCM anorectal planners. In terms of theoretical knowledge assessment, the scores of students in the experimental group were significantly better than those in the control group, indicating that this teaching mode helped students to better master the theoretical knowledge of TCM anorectal subject. In the practical skills examination, the students in the experimental group performed better in medical history collection, physical examination, Chinese medicine skill operation and western medicine skill operation, indicating that the students' practical ability was effectively improved. In addition, students have a high degree of satisfaction with the CBL combined with OSCE teaching model, believing that the model can stimulate learning interest, improve learning enthusiasm, and cultivate the ability to solve practical problems and team spirit.\u003c/p\u003e\u003cp\u003eThe CBL combined with OSCE teaching model has important application value and feasibility in the teaching of TCM anorectal planning and training physicians. Through the analysis and discussion of real cases, students can combine theoretical knowledge with clinical practice closely to improve clinical thinking ability and problem-solving ability. On the other hand, OSCE's comprehensive assessment can timely identify students' shortcomings and provide the basis for teaching improvement. Therefore, the teaching model is worthy of further promotion and application in the teaching of TCM anorectal planning and training, in order to cultivate more high-quality TCM anorectal professionals.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e7.2 Research Deficiencies and Prospects\u003c/h2\u003e\u003cp\u003eAlthough some results have been achieved in this study, there are still some shortcomings. Although the baseline of the two groups was balanced, the past clinical experience of the trainees was not controlled, which may influence the results and further covariate analysis needs to be included in the future. The relatively small sample size (n\u0026thinsp;=\u0026thinsp;60) may affect the universality and reliability of the research results. As a result, subsequent studies can include multi-center large sample verification, covering more TCM anorectal planners, in order to improve the credibility of the research results. The research time is short, and it is difficult to evaluate the long-term effect with the two-month training cycle. There is lack of in-depth tracking and evaluation of the long-term effect of CBL combined with OSCE teaching model. The follow-up study can carry out long-term follow-up investigation to observe the students' performance in clinical work after graduation, so as to comprehensively evaluate the impact of the teaching mode on the professional development of students\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn addition, in the selection and design of teaching cases, although the common TCM anorectal diseases have been covered as far as possible, the cases involving some rare and difficult diseases are less. In the future, we can further enrich the case database and add cases of rare and difficult diseases to broaden students' knowledge and clinical thinking\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. At the same time, the setting of OSCE examination station and the establishment of scoring criteria can be further optimized and improved to more scientifically, reasonably and objectively reflect the clinical ability of students\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn the future research, we can also explore the integration of CBL combined with OSCE teaching mode and other teaching methods, such as problem-based learning (PBL), simulation teaching, to further improve the teaching effect\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e. At the same time, with the continuous development of information technology, online teaching resources can also be combined with offline teaching to carry out hybrid teaching, to provide more rich and diverse learning experience for students\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll methods were carried out in accordance with the Helsinki Declaration. All subjects obtained informed consent orally, and the investigation was anonymous and voluntary, which was approved by the Ethics Committee of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine. The Ethics Committee of the First Affiliated Hospital of Henan University of Traditional Chinese Medicine gave up the need for ethical examination and approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this publishedarticle.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by the Cultivation Project of Henan University of Traditional Chinese Medicine, with the project number as 242301420114.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLi carried out experiments and wrote papers, and collected and analyzed the data. Zhang designed the experiment, revised the paper and supervised the work. All the authors participated in the design of the questionnaire, read and approved the final draft.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wishes to thank Henan University of Traditional Chinese Medicine for providing funds to support this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe Email Address of the Corresponding Author\u003c/strong\u003e\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGao Yisha H, Yazhou L, Yanhua Y, Huiling S, Xiaochen H, Hao. He Miaoxia Teaching and Learning of Standardized Training for Resident Physicians in Clinical Pathology Bases [J]. J Clin Experimental Pathol. 2024;40(10):1106\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLu Wanyuan Z, Jiangyi PY. and Nie Yongzhan Application of PBL combined with CBL teaching in standardized training of resident physicians for tumor immunotherapy [J/OL]. J Cell Mol Immunol, 1\u0026ndash;7 \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.13423/j.cnki.cjcmi.009973\u003c/span\u003e\u003cspan address=\"10.13423/j.cnki.cjcmi.009973\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChen Guanghua H, Guizhi T, Xiaoyan L, Han W, Xinlu. Ye Shicai Comprehensive Application Analysis of Multiple Teaching Methods in the Reform of Pathogenic Biology Teaching [J]. Chin J Pathogenic Biology. 2022;17(07):868\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Songmei G, Jing L, Jiazhen M, Xin. Zhou Jiaomei Application of Objective Structured Clinical Examination in Standardized Training of New Nurses in Traditional Chinese Medicine Hospitals [J]. China Nurs Manage. 2024;24(12):1819\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGuo J, Dong LYW. Peng Meiyu Preliminary exploration of the application of RBL combined with PBL teaching mode in medical immunology teaching [J]. Chin J Immunol. 2022;38(17):2136\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang, Min. Guo Shengbin Exploration and Research on the Teaching Reform of Pathogenic Biology in Oral Medicine Major Guided by Clinical Thinking [J]. Chin J Pathogenic Biology. 2025;20(05):687\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang, Ming. Wu Chuyan Application of Clinical Teaching Based on the Recommended Guidelines for Clinical Treatment of Scar Scars in China in Standardized Training for Resident Physicians in Plastic and Burn Surgery and Rehabilitation Departments [J]. Chin J Rehabilitation Med. 2024;39(09):1369\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao Xiaohui W, Bao Y, Yonghe. Li Xuejiao, Xie Yongsheng Comparative Study on the Application and Effectiveness of PBL and CBL Teaching Methods in Pathogenic Biology Teaching [J]. Chin J Pathogenic Biology. 2025;20(03):408\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang, Xintong. Zheng Yu Application of bedside team teaching method combined with case-based teaching method in severe cardiopulmonary rehabilitation teaching [J]. Chin J Rehabilitation Med. 2023;38(10):1429\u0026ndash;31.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDong Wenjing Z, Qian Z, Ruifang L, Xiaole C, Gege. Duan Xuan, Han Shifan Construction of Core Belief Professional Behavior Framework for Advanced Practice Nurses in China [J]. Nurs Res. 2025;39(02):183\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJingwen H. Xu Jiali Research on the Application of CBL Teaching Method in Clinical Internship Course of Diagnosis [J]. Chinese University Teaching; 2021. pp. 66\u0026ndash;8. 03.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSong Lan S, Hao Z, Daming X, Huadan C, Xuan YW, Wei S. Jin Zhengyu Application of Objective Structured Clinical Examination in Standardized Training Graduation Examination for Resident Physicians [J]. J Chin Acad Med Sci. 2021;43(06):922\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Mingjun J, Xuan G, Xiaojuan G, Weibing. Zhou Jin Clinical Digestive Medicine Teaching Reform Based on CBL and Experiential Teaching Concept [J]. Experimental Technol Manage. 2021;38(07):214\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou Xuanxuan Y, Qian B, Linlin W. Integrating traditional apprenticeship and modern educational approaches in traditional Chinese medicine education.[J]. Med Teach. 2023;46(6):11\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAttenborough Paul T, Jacquelyn F, Azharuddin F, Kylie. Clinical assessment during a global pandemic - transitioning to a COVID Safe hybrid OSCE.[J]. Int J Osteopath medicine: IJOM. 2021;42:1\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang Jun Z, Xiaobo L, Shijun W, Yulin. Marin Application of case teaching method based on Internet platform in radiology diagnostics teaching [J]. Chin J Med Imaging. 2022;30(08):852\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eXingyun L, Guolin D, Quan C. Hu Hongpu Design of Rare Disease Knowledge Base and Model Base [J]. Chin J Gen Pract. 2021;24(28):3634\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHomer Matt. Setting defensible minimum-stations-passed standards in OSCE-type assessments.[J]. Med Teach. 2023;45(10):1\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhan Jingyan L, Jingqiu W, Shaokun C, Wei. Song Shaojie Research on the Standardized Training and Teaching Mode and Application Effect of General Practitioners in China [J]. Chin J Gen Pract. 2021;24(19):2401\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu Yushu W, Dong Z, Guifang YS, Wei Z. Yao Tianling Analysis of the application effect of blended learning combined with the 5E teaching mode in general residency training teaching [J]. China Hosp Manage. 2023;43(05):85\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"CBL, OSCE, Traditional Chinese Medicine Anorectal Department, standardized training of residents, integrated Traditional Chinese and Western Medicine Teaching","lastPublishedDoi":"10.21203/rs.3.rs-7287583/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7287583/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e：To explore the application effect of case-based learning ( CBL ) combined with objective structured clinical examination ( OSCE ) in the standardized training of anorectal residents of traditional Chinese medicine.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e：From June 2023 to December 2024, 60 residents who received standardized training of residents in the anorectal department of the First Affiliated Hospital of Henan University of Tradit ional Chinese Medicine were randomly divided into experimental group ( CBL + OSCE, n = 30 ) and control group ( traditional teaching, n = 30 ). The teaching effects of different teaching methods were evaluated by comparing the examination results ( theory, skill operation, case analysis ), teaching satisfaction and clinical thinking ability of the two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e：The scores of theoretical achievement ( 89.5 ± 4.2 vs. 82.1 ± 5.6 ), skill operation ( 91.3 ± 3.8 vs. 85.4 ± 4.5 ), case analysis ( 93.2 ± 2.9 vs. 87.6 ± 3.7 ), teaching satisfaction and clinical thinking ability in the experimental group were significantly higher than those in the control group ( all P \u0026lt; 0.05 ).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e：With the advantages of combining theory with practice, the CBL combined with OSCE teaching mode realizes the integrated training of Chinese and Western medicine diagnosis and treatment ability for the firs t time in the anorectal training of traditional Chinese medicine, which significantly improves the teaching effect and provides an innovative solution for the training of anorectal professionals of traditional Chinese medicine.\u003c/p\u003e","manuscriptTitle":"Research on the Application of CBL Combined with OSCE in the Teaching of Anorectal Standardized Training Physician of Traditional Chinese Medicine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-18 18:12:44","doi":"10.21203/rs.3.rs-7287583/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-09-19T01:29:20+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101568564866167726746572583666441731537","date":"2025-09-12T03:32:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-11T11:41:05+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-03T06:58:34+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-08-13T08:27:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-12T06:59:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-08-12T06:56:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meed","sideBox":"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meed/default.aspx","title":"BMC Medical Education","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6fb96223-1c84-473d-a84d-8aba6f41c7e3","owner":[],"postedDate":"September 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-18T18:12:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-18 18:12:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7287583","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7287583","identity":"rs-7287583","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}