The blended clinical internship model based on MOOC and digital twin technology in optometry teaching

The blended clinical internship model based on MOOC and digital twin technology in optometry teaching | 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 The blended clinical internship model based on MOOC and digital twin technology in optometry teaching Yang Kang, Kanwen Wang, Jing Cui, Zidan Guo, Chenggong Jiang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7042220/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: In optometry education, insufficient theoretical depth and limited practical opportunities during clinical rotations contribute to gaps in theoretical knowledge and operational skills. While MOOCs offer flexible resource integration and digital twin technology provides high-fidelity simulation, standalone applications have limitations. This study therefore evaluated the effectiveness and acceptability of a novel MOOC-digital twin hybrid clinical internship model in optometry, specifically assessing its impact on students' theoretical mastery, clinical operational ability, and comprehensive learning experience, to provide empirical evidence for educational reform. Methods: Fifty-four ophthalmology graduate students were divided into an experimental group and a control group. The experimental group utilized the MOOC platform for pre-class theoretical learning and employed digital twin technology to simulate corneal refractive surgery procedures. The control group received traditional classroom lectures and demonstrations. Learning outcomes were compared using in-class tests, final subject assessments (theoretical and practical), and questionnaires. Data were analyzed using independent samples t-tests. Results: The experimental group achieved significantly higher scores in both refractive surgery (pre-test: t = 4.096, P < 0.001; final exam: t = 3.642, P = 0.001) and amblyopia modules (t = 2.33, P = 0.024), with progressive improvement over time. They also reported superior teaching satisfaction, task-clinical relevance, and course interest (all P < 0.05). Instructors (92%) noted enhanced student comprehension and improved learning climate (t = 6.211, P < 0.001). Conclusions: The MOOC-digital twin hybrid mode, structured around a "theory → simulation → practice" framework, effectively synergizes the flexibility of MOOCs with the practical realism of digital twins, significantly enhancing students' active learning capabilities and clinical reasoning in optometry training. This study provides empirical support for the model's efficacy as a tool for medical education innovation. Blended learning optometry Master education Self-directed learning ability Self-efficacy Figures Figure 1 Figure 2 Figure 3 Background Within the master's program for clinical medicine graduate students, the curricular framework is integrated with the standardized residency training (SRT) requirements. Upon graduation, these students are expected to possess not only foundational clinical research aptitude but also clinical diagnostic and therapeutic competencies equivalent to those of a senior resident physician [ 1 ] . Consequently, a significant challenge lies in enabling these master's students to acquire comprehensive clinical competencies during their designated departmental rotations and effectively translate this learning into flexible clinical application. Optometry represents a distinct subspecialty characterized by abstract and complex theoretical foundations that are largely independent from general ophthalmology. This separation, coupled with limited clinical exposure opportunities, creates significant learning barriers. Consequently, when ophthalmology graduate students undertake optometry rotations, deficits such as an inadequate grasp of core concepts, difficulty integrating theory with practice, and impaired clinical performance frequently emerge. These challenges represent a growing educational concern. The Massive Open Online Course (MOOC) model delivers instructional content through diverse resources (e.g., short videos, animations), enhancing knowledge dissemination efficiency [ 2 ] . Increasingly integrated into medical education, MOOCs improve comprehension, mitigate online disengagement, and demonstrate favorable outcomes. However, they remain insufficient for disciplines requiring hands-on skills or credentialing [ 3 – 5 ] . A Digital Twin (DT) is a dynamic, multi-scale digital replica simulating real systems. Recently integrated into engineering education, DT technology enables convenient observation, remote practice, and conceptual reinforcement, facilitating operational proficiency. Within the past two years, engineering educators in higher institutions have initiated the integration of DT technology into pedagogical frameworks [ 6 , 7 ] . While successfully applied in medical imaging training [ 8 ] , its implementation in ophthalmology and optometry education represents a significant knowledge gap [ 9 ] . Blended learning integrates traditional classroom instruction with structured online activities within a flipped classroom model. This approach transfers primary learning agency to students, who independently engage with curated digital content prior to face-to-face sessions [ 10 , 11 ] . Crucially, the online component provides equitable access to uniformly high-quality instructional resources, empowering learners to conduct self-directed study and formative self-assessment [ 12 ] . The core pedagogical objective of blended learning is to cultivate self-directed, personalized learning where each student becomes an active protagonist, leveraging rich digital repositories while maintaining cohort cohesion within the traditional classroom framework. Over the past five years, emerging adoption of MOOC-enhanced flipped classrooms has been documented across higher education [ 13 ] , including undergraduate and graduate medical programs with preliminary efficacy data [ 14 ] . However, this model demands advanced digital fluency among educators and risks inadequate subject-specific scaffolding for personalized learning trajectories alongside insufficient practical skill development [ 15 ] . Informed by the inherent complexity of optometric science and variable clinical proficiency levels among trainees, we implemented a blended pedagogical framework integrating online and offline modalities. The online component centers on a MOOC-based digital learning ecosystem, leveraging information technology to deliver curated content through dynamic visualization of abstract theoretical concepts. This platform employs specialized software applications and multimedia production techniques to establish a structured virtual learning environment. During offline sessions, instructors contextualize and synthesize knowledge, redesign clinical didactics, and facilitate high-fidelity procedural rehearsal using digital twin technology for refractive surgery simulation. This integrated approach fosters self-directed learning competencies while enhancing clinical self-efficacy in postgraduate trainees. In this study, we evaluated for the first time the effectiveness and acceptability of blended learning mode for ophthalmic graduate students at Harbin Medical University School of Ophthalmology during their clinical learning phase in the fall of 2023. The purpose of this study is to provide quantitative data on the effectiveness of a blended clinical internship model based on MOOC technology and digital twin technology in teaching ophthalmic knowledge to medical students in the application of optometry. This article has certain guiding significance for optometry teachers to implement and develop better practices in future optometry teaching. Methods Study design and sample The participants of this study (n = 54) are master's students majoring in ophthalmology from the 2023 class, who are included in the teaching arrangement of the Ophthalmology Teaching and Research Department of the First Affiliated Hospital of Harbin Medical University. After being reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Harbin Medical University, and after sufficient communication with graduate students, they were divided into two groups according to their own wishes and entered the Ophthalmic Optometry Center for study. The first group underwent a mixed clinical internship mode of MOOC and digital twin technology with corneal refractive surgery as the theme, while the second group underwent a regular internship mode as a control. Teaching arrangements Prior to clinical placement, experimental group participants completed a structured 6-day MOOC curriculum comprising five sequential modules (Table 1 ). On Day 1, learners accessed a dedicated optometric education platform to engage with self-directed video instruction covering core concepts in corneal refractive surgery, including: surgical principles; indications/contraindications; procedural techniques; postoperative management; and complication mitigation protocols. Surgical indication and complication-focused assessments (employing A1, A2, A3/A4, and X-type structured formats) were subsequently deployed via the platform. All learner submissions underwent systematic collection, blinded correction, and analytical aggregation. Final performance metrics were disseminated in real-time to both instructors and participants, enabling iterative verification of conceptual mastery. Digital twin technology demonstrations illustrating corneal refractive surgery procedures were made available on the platform one day prior to clinical practice commencement. Mandatory viewing requirements were implemented for the experimental group, while no preparatory materials were provided to the control group. During clinical practice orientation, key concepts and operational challenges were reinforced through instructor-led summaries for the experimental group. Step-by-step simulations of femtosecond laser corneal flap creation, flap opening techniques, and excimer laser ablation procedures were conducted. All practical demonstrations were accompanied by individualized guidance, enabling repeated practice until operational proficiency was achieved. A comprehensive review of theoretical foundations and technological applications was conducted at program conclusion, followed by immediate competency assessments. The control group received standard classroom instruction consisting of teacher demonstrations and explanations without supplementary materials or post-class assignments. Table 1 Relevant Teaching Arrangements within One Week Before Clinical Internship Part Date Content Ⅰ 1st day Student self-learning clinical internship related videos Ⅱ 3rd day Students answer relevant test questions Ⅲ 4th day Teachers correct, summarize, and publish test questions Ⅳ 5th day Students watch and understand the specific operational steps of the digital twin technology model Ⅴ 6th day Classroom teaching and digital twin technology simulation operation on the day of the internship Evaluation This study evaluates the experimental results using evaluation indicators for both the teaching process and teaching effectiveness. The evaluation indicators for the teaching process include: ① Quantifying graduate students' satisfaction with teaching through questionnaire surveys; ② Allowing students to conduct subjective qualitative evaluations of the teaching process; ③ Quantitative survey on the comfort level of teaching experience for teachers (referring to mixed teaching effectiveness questionnaires at home and abroad, conducting validity tests on the survey format and content). The evaluation indicators for teaching effectiveness include conducting graduate student in-class tests and exit assessments, which include theoretical knowledge assessments, patient consultations, eye examinations, medical record writing, diagnosis and differential diagnosis, disease recognition assessments for proposing treatment plans, and hands-on ability assessments for clinical examinations and standardized operations. Statistical analysis Compare two teaching modes pairwise between groups, using ANOVA for repeated measurement data. If there is a statistically significant difference, further inter-group comparison will be conducted using an independent sample t-test. Count data will be represented by rate, and inter-group comparison will be conducted using the chi-square test. Using SPSS21.0, with P < 0.05 as the significance standard, the teaching effect of blended learning was determined. Figure 1 Participants flow diagram Results A total of 54 graduate students were enrolled in this study, with 27 participants being assigned to a blended clinical internship program incorporating MOOC technology and digital twin technology. All participants were required to complete pre-class assessments, post-class evaluations, and final examinations. Significant statistical differences were observed in pre-class test scores between the two groups for both refractive course content (t = 4.096, P = 0.0001) and amblyopia course content (t = 3.199, P = 0.002). These results indicated that greater mastery of learning materials had been achieved by the experimental group through pre-class preparation (Fig. 2 A). In post-class assessments, statistically significant differences were recorded between groups for refractive course scores (t = 5.735, P = 0.000005) and amblyopia course scores (t = 2.667, P = 0.01). Superior performance was consistently demonstrated by the experimental group compared to the control group (Fig. 2 B). Final examination results revealed significantly higher scores were attained by the experimental group in refractive course content (t = 3.642, P = 0.0006). Although performance advantages were maintained in amblyopia course content (t = 2.33, P = 0.024), a relatively smaller difference was observed between groups (Fig. 2 C). Comparative analysis of pre-class assessments, post-class evaluations, and final examination results confirmed statistically significant performance advantages were maintained by the experimental group across both course modules. This outcome suggests that pre-class learning activities positively influenced content mastery and academic achievement. Furthermore, progressive enhancement of scoring advantages was noted in the experimental group over time (from pre-class assessments through final examinations), particularly in refractive course content. This temporal pattern may indicate sustained benefits of the blended clinical internship model for long-term knowledge retention. All students and teachers completed the questionnaires at the end of the session, with a response rate of 100%. Table 2 Comparison of Course Experience between Traditional Teaching Group and Blended Teaching Group Teaching methods P value Traditional Teaching Group Blended learning group Good Teaching 4.074 ± 0.282 4.796 ± 0.246 0.000* Generic Skills 4.173 ± 0.322 4.790 ± 0.247 0.000* Clear Goals and Standard 3.583 ± 0.422 4.139 ± 0.451 0.000* Appropriate Workload 2.185 ± 0.226 3.306 ± 1.112 0.000* Appropriate Assessment 2.148 ± 0.187 2.852 ± 0.785 0.000* Two groups underwent independent sample t-test comparison * P < 0.05 indicates a statistical difference Table 2 summarizes the course experience feedback of students in classroom teaching, mastery of basic skills, goals and standards, appropriate assignments, and appropriate assessments. Interestingly, there were significant differences in feedback between the two groups of students in various aspects. Compared with traditional teaching classrooms, students believe that blended learning provides a better experience in classroom teaching (t = 10.019, P = 0.000), basic skill mastery (t = 7.904, P = 0.000), clear goals (t = 4.674, P = 0.000), appropriate homework (t = 5.101, P = 0.000), and appropriate assessment (t = 4.530, P = 0.000). Table 3 Comparison of Traditional Teaching Group and Blended Teaching Group in the Learning Process Teaching methods P value Traditional Teaching Group Blended learning group Deep Motivation(DM) 4.669 ± 0.386 4.312 ± 0.183 0.000* Deep Strategy(DS) 4.676 ± 0.340 4.352 ± 0.194 0.000* Surface Motivation(SM) 3.676 ± 1.245 4.384 ± 0.199 0.007* Surface Strategy(SS) 3.655 ± 1.279 4.432 ± 0.229 0.004* Two groups underwent independent sample t-test comparison * P < 0.05 indicates statistical difference Table 3 summarizes the comparison of students' deep motivation, deep strategy, surface motivation, and surface strategy in the learning process. The traditional teaching group outperformed the blended learning group in terms of deep motivation (t = 4.257, P = 0.000) and deep strategy (t = 4.208, P = 0.000). The blended learning group outperformed the traditional teaching group in terms of surface motivation (t = 2.810, P = 0.007) and surface strategy SS (t = 2.991, P = 0.004). Table 4 Feedback from Trainee Teachers in Traditional Teaching Group and Blended Teaching Group Teaching methods P value Traditional Teaching Group Blended learning group The lecture greatly enhanced students' understanding of this topic. 3.130 ± 0.619 4.750 ± 0.447 0.000* The course met my expectations. 3.190 ± 0.544 4.560 ± 0.512 0.000* It is an enjoyable way of teaching. 3.500 ± 0.516 4.690 ± 0.479 0.000* Overall, I am satisfied with the quality of this course. 3.500 ± 0.516 4.630 ± 0.619 0.000* The climate of this class is conducive to learning for students. 3.440 ± 0.512 4.560 ± 0.512 0.000* Two groups underwent independent sample t-test comparison * P < 0.05 indicates statistical difference Table 4 summarizes the feedback from two groups of trainee teachers, the traditional teaching group and the blended learning group. Compared with traditional teaching methods, more teachers believe that blended learning can improve students' understanding of learning content (t = 8.510, P = 0.000), meet their expectations (t = 7.361, P = 0.000), and is a pleasant teaching method (t = 6.746, P = 0.000). They are more satisfied with the quality of blended classrooms (t = 5.582, P = 0.000), and the class atmosphere is more conducive to students' learning (t = 6.211, P = 0.000). In addition, most teachers believe that corneal refractive surgery is a more suitable topic for a blended learning mode (Fig. 3 A), which can be conducted once a week during probationary teaching (Fig. 3 B). Discussion This study is the first to evaluate the effectiveness of a blended clinical practice model based on MOOC and digital twin technology in the teaching of optometry. The study found that this blended teaching model got better teaching results and was loved by the participating teachers and students. Several factors potentially explain these outcomes: (1) Enhanced Cognitive Engagement. The blended clinical internship model integrates MOOC-based tasks with digital twin-simulated surgical procedures, fostering deeper student immersion. This synergy promotes profound conceptual understanding and procedural mastery [ 16 , 17 ] , while concurrently developing proactive problem-solving skills. Consequently, students demonstrate improved academic performance and clinical reasoning, facilitating deeper learning processes [ 18 , 19 ] . (2) Learner-Centered Design. Emphasizing learner autonomy, the blended clinical internship model accommodates personalized needs and interests through self-directed content selection. Integrated MOOC and digital twin technologies provide real-time performance analytics, enabling students to accurately identify knowledge gaps and dynamically optimize learning strategies. This metacognitive feedback loop significantly enhances self-regulated learning capabilities and self-efficacy among graduate trainees [ 20 ] . (3) Adaptive Learning Flexibility. The blended clinical internship model addresses inherent limitations of traditional didactic approaches—such as attentional fragmentation and constrained review opportunities—by incorporating on-demand video resources [ 21 ] . Learners exert granular control over study schedules, locations, and repetition frequency, aligning instruction with individual cognitive preferences. This inherent adaptability ensures educational responsiveness to rapidly evolving healthcare demands [ 22 ] . (4) Theory-Practice Integration and Enhanced Interactivity. The model systematically bridges theoretical knowledge with clinical application, enabling iterative reinforcement through simulated practice [ 23 ] . Furthermore, its structured interactive framework facilitates timely instructor feedback and scaffolding support. These features collectively increase learning motivation, foster intrinsic engagement, and strengthen knowledge retention [ 24 – 26 ] . In summary, this study indicates that the blended clinical internship model is widely welcomed by medical students and can effectively improve their academic performance. This indicates that the blended clinical internship model may be a direction for the reform of internship teaching for optometry students. By observing the evaluation of the teaching process and teaching effectiveness, the blended clinical internship model based on MOOC and digital twin technology has significantly better short-term and long-term learning effects than traditional teaching methods. The experimental group has a sustained advantage in refractive classes, with the differences in their scores before, after, and at the end of the exam gradually widening. This indicates that students can gain a deeper understanding of procedural knowledge through the "theory simulation practical" framework that combines pre-course MOOC module learning with offline clinical practice. However, the small performance gap in amblyopia classrooms also highlights the limitations of blended learning in the experience dependent domain. The experimental group maintained a stable advantage in the final exam, indicating that the blended learning model not only enables students to master the basic knowledge required in teaching, but also significantly exercises their clinical thinking ability for ophthalmic optical diseases, truly cultivating students' comprehensive ability to analyze and solve practical problems [ 17 ] . However, exam scores only reflect the level of theoretical mastery, and longitudinal research is needed to verify whether this model truly enhances decision-making ability in real clinical environments. Despite the many benefits of blended learning, traditional instruction is more effective at fostering deep motivation and techniques (Table 2 ). This suggests that the benefits of both traditional teaching methods and blended learning may be able to be combined [ 27 ] . Furthermore, the soft skills acquired through blended learning could be overlooked by the present evaluation system, which is based on exam results. Multimodal indications, such peer evaluations and simulated clinical exams, can be added in the future to fully gauge students' aptitudes. [ 28 ] . Conclusions This innovative and revolutionary teaching method demonstrates significant potential for broader educational applications in ophthalmic and optometric education as a proven instructional strategy. This approach significantly enhances technical skill acquisition and consistently improves short-term learning outcomes, as evidenced by multiple studies. However, the development of higher-order cognitive skills necessitates systematic integration with traditional didactic instruction [ 29 , 30 ] . This educational paradigm bridges technological gaps in medical training, strategically redefines instructor roles to align with digital competencies, and establishes flexible, competency-based curriculum frameworks. Consequently, it fosters lifelong learning capacity in students, enabling them to adapt to rapidly evolving healthcare landscapes. This graduate-centered blended clinical internship model, integrating MOOC platforms with digital twin technology, leverages the synergistic effects of technological innovation and self-directed learning to transform traditional didactic approaches into an interactive, cognitively engaging, and clinically rich educational paradigm. Beyond cultivating capacities for autonomous learning, higher-order cognitive abilities, and practical clinical skills, it enables the flexible application of theoretical knowledge to disease diagnosis and treatment, establishing a robust foundation for evidence-based clinical practice [ 31 , 32 ] . Abbreviations SRT standardized residency training MOOC massive open online course DT digital twin Declarations Ethics approval and consent to participate Approval was obtained from the Ethics Committee of the First Affiliated Hospital of Harbin Medical University. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Clinical trial number: not applicable. Consent for publication Not applicable. Availability of data and materials All data generated or analysed during this study are included in this published article. Competing interests All authors declare no competing interest in this work. Funding Research on the Hybrid Clinical Internship Model Based on MOOC and Digital Twin Technology in the Teaching of Ophthalmology and Optometry Graduate Students, General Research, 2022 [SJGY20220268] Research and Practice of Multidimensional Stereoscopic Teaching Mode Based on OBE Concept in the Cultivation of Ophthalmic Graduate Students, Key Project of the 14th Five Year Plan for Education Science in Heilongjiang Province in 2022 [GJB1422773] Authors' contributions All authors contributed to the study conception and design. Teaching preparation, student organization, data collection and analysis were completed by Yang Kang, Kanwen Wang, Jing Cui, Zidan Guo, Chenggong Jiang and Xue Li. The initial draft of the manuscript was written by Kanwen Wang, and all authors have commented on the previous versions of the manuscript. All authors have read and approved the final manuscript. Acknowledgements None. Authors' information Yang Kang 1# , Kanwen Wang 2# , Jing Cui 1 , Zidan Guo 3 , Chenggong Jiang 1 , Xue Li 1 1 Eye Hospital, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China. 2 Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China. 3 Outpatient department of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province, People’s Republic of China. # These authors contributed equally to this work. Correspondence: Xue Li, Eye Hospital，The First Affiliated Hospital of Harbin Medical University, No. 143， Yiman Street, Harbin, Heilongjiang Province 150001, China (e-mail: [email protected] ). Footnotes None. References MORRISSEY B, HEILBRUN ME. Teaching Critical Thinking in Graduate Medical Education: Lessons Learned in Diagnostic Radiology [J]. J Med Educ Curric Dev. 2017;4:2382120517696498. SHI Y, ZHANG J, SHI F, et al. 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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-7042220","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497356048,"identity":"8fc4e18d-4f3f-4d43-b62d-89f1e8634903","order_by":0,"name":"Yang Kang","email":"","orcid":"","institution":"Eye Hospital, The First Affiliated Hospital of Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yang","middleName":"","lastName":"Kang","suffix":""},{"id":497356049,"identity":"ea107239-1277-4a60-95b4-e099c1d7cb65","order_by":1,"name":"Kanwen Wang","email":"","orcid":"","institution":"Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kanwen","middleName":"","lastName":"Wang","suffix":""},{"id":497356050,"identity":"329eefdf-a6f2-4316-b2df-d5d26e61f7fc","order_by":2,"name":"Jing Cui","email":"","orcid":"","institution":"Eye Hospital, The First Affiliated Hospital of Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Cui","suffix":""},{"id":497356051,"identity":"0a20ace1-1817-45c9-a7eb-3b1072962a43","order_by":3,"name":"Zidan Guo","email":"","orcid":"","institution":"Outpatient department of Harbin Medical University, Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zidan","middleName":"","lastName":"Guo","suffix":""},{"id":497356052,"identity":"9a6826ba-8124-4f8c-a219-1e915869bf95","order_by":4,"name":"Chenggong Jiang","email":"","orcid":"","institution":"Eye Hospital, The First Affiliated Hospital of Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Chenggong","middleName":"","lastName":"Jiang","suffix":""},{"id":497356053,"identity":"ccfa492f-cd3c-4ff3-a66c-2148298ba8ff","order_by":5,"name":"Xue Li","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIie3RscrCMBDA8ZNApmLWK0i/VwgInfowF4RMCo4dBBXFDiKu+haOjpVCXOLu2L6B36aLWGfF1M0hvzl/LpcAeN4P4iI7XihNIiFmh5LSkTtpo9VQWt0NN6YnS2vcSQQUt6pFoXZ5Pw6rOWtwMch1SVy3thOjUzXhILIlfU7Y9CgpSJhgM3NW+w6gPe1cUwgJNQ/rKWdlOUgcuBKSSLIIZL3LUC1YoyRGogKfCTRL0PYk5Vo+HxnJmsC5y986O1S3ezJe11/5f01HkchWn5MXwXfHPc/zvLceNfpPqRGLZm0AAAAASUVORK5CYII=","orcid":"","institution":"Eye Hospital, The First Affiliated Hospital of Harbin Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xue","middleName":"","lastName":"Li","suffix":""}],"badges":[],"createdAt":"2025-07-04 02:23:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7042220/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7042220/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88777735,"identity":"4db9d521-8ae4-445f-9153-7811f1a2a306","added_by":"auto","created_at":"2025-08-11 10:15:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39631,"visible":true,"origin":"","legend":"\u003cp\u003eParticipants flow diagram\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7042220/v1/8c7fe422022a5d713e7f7b2a.png"},{"id":88773835,"identity":"07aed531-047a-405e-a377-b138b59132cc","added_by":"auto","created_at":"2025-08-11 09:59:12","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":431619,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of students' exam scores before and after class, as well as during the final exam. Students are required to answer questions before (A) and after (B) class. Each question has the same weight, with a total score of 100 points for pre-class and post-class tests, and a total score of 10 points for the final exam. Use an independent sample t-test to compare the differences between the two groups. All data are presented as mean ± S.D. n=27. （*：P\u0026lt;0.05，**：P\u0026lt;0.01，***：P\u0026lt;0.001，NS：P\u0026gt;0.05）\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7042220/v1/a76a42bfa39e66974f2d8ec6.jpeg"},{"id":88773827,"identity":"ba96a2d2-a832-4f78-91b3-d53f25653ef8","added_by":"auto","created_at":"2025-08-11 09:59:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":53800,"visible":true,"origin":"","legend":"\u003cp\u003eTeachers' views on the frequency and scope of using classroom models in ophthalmology teaching. Teachers (n=32) were asked to select 1 to 3 themes (A) that they believed were most suitable for applying blended learning mode. Teachers were also asked how many times they had thought about how flipped classrooms could be implemented in apprenticeship teaching (B).\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-7042220/v1/840f4d793048af5ed10bf5c7.png"},{"id":88778234,"identity":"b3775849-f5bd-49c8-ae95-1cf2446756b4","added_by":"auto","created_at":"2025-08-11 10:23:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1183756,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7042220/v1/80f1474f-417d-457f-8112-b532d60c6d88.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The blended clinical internship model based on MOOC and digital twin technology in optometry teaching","fulltext":[{"header":"Background","content":"\u003cp\u003eWithin the master's program for clinical medicine graduate students, the curricular framework is integrated with the standardized residency training (SRT) requirements. Upon graduation, these students are expected to possess not only foundational clinical research aptitude but also clinical diagnostic and therapeutic competencies equivalent to those of a senior resident physician\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Consequently, a significant challenge lies in enabling these master's students to acquire comprehensive clinical competencies during their designated departmental rotations and effectively translate this learning into flexible clinical application.\u003c/p\u003e\u003cp\u003eOptometry represents a distinct subspecialty characterized by abstract and complex theoretical foundations that are largely independent from general ophthalmology. This separation, coupled with limited clinical exposure opportunities, creates significant learning barriers. Consequently, when ophthalmology graduate students undertake optometry rotations, deficits such as an inadequate grasp of core concepts, difficulty integrating theory with practice, and impaired clinical performance frequently emerge. These challenges represent a growing educational concern.\u003c/p\u003e\u003cp\u003eThe Massive Open Online Course (MOOC) model delivers instructional content through diverse resources (e.g., short videos, animations), enhancing knowledge dissemination efficiency\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. Increasingly integrated into medical education, MOOCs improve comprehension, mitigate online disengagement, and demonstrate favorable outcomes. However, they remain insufficient for disciplines requiring hands-on skills or credentialing\u003csup\u003e[\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eA Digital Twin (DT) is a dynamic, multi-scale digital replica simulating real systems. Recently integrated into engineering education, DT technology enables convenient observation, remote practice, and conceptual reinforcement, facilitating operational proficiency. Within the past two years, engineering educators in higher institutions have initiated the integration of DT technology into pedagogical frameworks\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. While successfully applied in medical imaging training\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e, its implementation in ophthalmology and optometry education represents a significant knowledge gap\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBlended learning integrates traditional classroom instruction with structured online activities within a flipped classroom model. This approach transfers primary learning agency to students, who independently engage with curated digital content prior to face-to-face sessions\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Crucially, the online component provides equitable access to uniformly high-quality instructional resources, empowering learners to conduct self-directed study and formative self-assessment\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe core pedagogical objective of blended learning is to cultivate self-directed, personalized learning where each student becomes an active protagonist, leveraging rich digital repositories while maintaining cohort cohesion within the traditional classroom framework. Over the past five years, emerging adoption of MOOC-enhanced flipped classrooms has been documented across higher education\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e, including undergraduate and graduate medical programs with preliminary efficacy data\u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. However, this model demands advanced digital fluency among educators and risks inadequate subject-specific scaffolding for personalized learning trajectories alongside insufficient practical skill development\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eInformed by the inherent complexity of optometric science and variable clinical proficiency levels among trainees, we implemented a blended pedagogical framework integrating online and offline modalities. The online component centers on a MOOC-based digital learning ecosystem, leveraging information technology to deliver curated content through dynamic visualization of abstract theoretical concepts. This platform employs specialized software applications and multimedia production techniques to establish a structured virtual learning environment. During offline sessions, instructors contextualize and synthesize knowledge, redesign clinical didactics, and facilitate high-fidelity procedural rehearsal using digital twin technology for refractive surgery simulation. This integrated approach fosters self-directed learning competencies while enhancing clinical self-efficacy in postgraduate trainees.\u003c/p\u003e\u003cp\u003eIn this study, we evaluated for the first time the effectiveness and acceptability of blended learning mode for ophthalmic graduate students at Harbin Medical University School of Ophthalmology during their clinical learning phase in the fall of 2023.\u003c/p\u003e\u003cp\u003eThe purpose of this study is to provide quantitative data on the effectiveness of a blended clinical internship model based on MOOC technology and digital twin technology in teaching ophthalmic knowledge to medical students in the application of optometry. This article has certain guiding significance for optometry teachers to implement and develop better practices in future optometry teaching.\u003c/p\u003e\u003c/div\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy design and sample\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The participants of this study (n = 54) are master's students majoring in ophthalmology from the 2023 class, who are included in the teaching arrangement of the Ophthalmology Teaching and Research Department of the First Affiliated Hospital of Harbin Medical University. After being reviewed and approved by the Ethics Committee of the First Affiliated Hospital of Harbin Medical University, and after sufficient communication with graduate students, they were divided into two groups according to their own wishes and entered the Ophthalmic Optometry Center for study.\u003c/p\u003e\u003cp\u003eThe first group underwent a mixed clinical internship mode of MOOC and digital twin technology with corneal refractive surgery as the theme, while the second group underwent a regular internship mode as a control.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTeaching arrangements\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePrior to clinical placement, experimental group participants completed a structured 6-day MOOC curriculum comprising five sequential modules (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). On Day 1, learners accessed a dedicated optometric education platform to engage with self-directed video instruction covering core concepts in corneal refractive surgery, including: surgical principles; indications/contraindications; procedural techniques; postoperative management; and complication mitigation protocols.\u003c/p\u003e\u003cp\u003eSurgical indication and complication-focused assessments (employing A1, A2, A3/A4, and X-type structured formats) were subsequently deployed via the platform. All learner submissions underwent systematic collection, blinded correction, and analytical aggregation. Final performance metrics were disseminated in real-time to both instructors and participants, enabling iterative verification of conceptual mastery.\u003c/p\u003e\u003cp\u003eDigital twin technology demonstrations illustrating corneal refractive surgery procedures were made available on the platform one day prior to clinical practice commencement. Mandatory viewing requirements were implemented for the experimental group, while no preparatory materials were provided to the control group.\u003c/p\u003e\u003cp\u003eDuring clinical practice orientation, key concepts and operational challenges were reinforced through instructor-led summaries for the experimental group. Step-by-step simulations of femtosecond laser corneal flap creation, flap opening techniques, and excimer laser ablation procedures were conducted. All practical demonstrations were accompanied by individualized guidance, enabling repeated practice until operational proficiency was achieved.\u003c/p\u003e\u003cp\u003e A comprehensive review of theoretical foundations and technological applications was conducted at program conclusion, followed by immediate competency assessments. The control group received standard classroom instruction consisting of teacher demonstrations and explanations without supplementary materials or post-class assignments.\u003c/p\u003e\u003cdiv class=\"gridtable\"\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\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\u003eRelevant Teaching Arrangements within One Week Before Clinical Internship\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePart\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDate\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eContent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅠ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1st day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudent self-learning clinical internship related videos\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅡ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3rd day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudents answer relevant test questions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅢ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4th day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeachers correct, summarize, and publish test questions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅣ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5th day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudents watch and understand the specific operational steps of the digital twin technology model\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eⅤ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6th day\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eClassroom teaching and digital twin technology simulation operation on the day of the internship\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eEvaluation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study evaluates the experimental results using evaluation indicators for both the teaching process and teaching effectiveness.\u003c/p\u003e\u003cp\u003eThe evaluation indicators for the teaching process include: ① Quantifying graduate students' satisfaction with teaching through questionnaire surveys; ② Allowing students to conduct subjective qualitative evaluations of the teaching process; ③ Quantitative survey on the comfort level of teaching experience for teachers (referring to mixed teaching effectiveness questionnaires at home and abroad, conducting validity tests on the survey format and content).\u003c/p\u003e\u003cp\u003eThe evaluation indicators for teaching effectiveness include conducting graduate student in-class tests and exit assessments, which include theoretical knowledge assessments, patient consultations, eye examinations, medical record writing, diagnosis and differential diagnosis, disease recognition assessments for proposing treatment plans, and hands-on ability assessments for clinical examinations and standardized operations.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCompare two teaching modes pairwise between groups, using ANOVA for repeated measurement data. If there is a statistically significant difference, further inter-group comparison will be conducted using an independent sample t-test. Count data will be represented by rate, and inter-group comparison will be conducted using the chi-square test. Using SPSS21.0, with P \u0026lt; 0.05 as the significance standard, the teaching effect of blended learning was determined. Figure\u0026nbsp;1 Participants flow diagram\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 54 graduate students were enrolled in this study, with 27 participants being assigned to a blended clinical internship program incorporating MOOC technology and digital twin technology. All participants were required to complete pre-class assessments, post-class evaluations, and final examinations.\u003c/p\u003e\u003cp\u003eSignificant statistical differences were observed in pre-class test scores between the two groups for both refractive course content (t\u0026thinsp;=\u0026thinsp;4.096, P\u0026thinsp;=\u0026thinsp;0.0001) and amblyopia course content (t\u0026thinsp;=\u0026thinsp;3.199, P\u0026thinsp;=\u0026thinsp;0.002). These results indicated that greater mastery of learning materials had been achieved by the experimental group through pre-class preparation (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eA).\u003c/p\u003e\u003cp\u003eIn post-class assessments, statistically significant differences were recorded between groups for refractive course scores (t\u0026thinsp;=\u0026thinsp;5.735, P\u0026thinsp;=\u0026thinsp;0.000005) and amblyopia course scores (t\u0026thinsp;=\u0026thinsp;2.667, P\u0026thinsp;=\u0026thinsp;0.01). Superior performance was consistently demonstrated by the experimental group compared to the control group (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e\u003cp\u003eFinal examination results revealed significantly higher scores were attained by the experimental group in refractive course content (t\u0026thinsp;=\u0026thinsp;3.642, P\u0026thinsp;=\u0026thinsp;0.0006). Although performance advantages were maintained in amblyopia course content (t\u0026thinsp;=\u0026thinsp;2.33, P\u0026thinsp;=\u0026thinsp;0.024), a relatively smaller difference was observed between groups (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e2\u003c/span\u003eC).\u003c/p\u003e\u003cp\u003eComparative analysis of pre-class assessments, post-class evaluations, and final examination results confirmed statistically significant performance advantages were maintained by the experimental group across both course modules. This outcome suggests that pre-class learning activities positively influenced content mastery and academic achievement.\u003c/p\u003e\u003cp\u003eFurthermore, progressive enhancement of scoring advantages was noted in the experimental group over time (from pre-class assessments through final examinations), particularly in refractive course content. This temporal pattern may indicate sustained benefits of the blended clinical internship model for long-term knowledge retention.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAll students and teachers completed the questionnaires at the end of the session, with a response rate of 100%.\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\u003eComparison of Course Experience between Traditional Teaching Group and Blended Teaching Group\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTeaching methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraditional Teaching Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBlended learning group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGood Teaching\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.074\u0026thinsp;\u0026plusmn;\u0026thinsp;0.282\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.796\u0026thinsp;\u0026plusmn;\u0026thinsp;0.246\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGeneric Skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.173\u0026thinsp;\u0026plusmn;\u0026thinsp;0.322\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.790\u0026thinsp;\u0026plusmn;\u0026thinsp;0.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eClear Goals and Standard\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.583\u0026thinsp;\u0026plusmn;\u0026thinsp;0.422\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.139\u0026thinsp;\u0026plusmn;\u0026thinsp;0.451\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAppropriate Workload\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.185\u0026thinsp;\u0026plusmn;\u0026thinsp;0.226\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e3.306\u0026thinsp;\u0026plusmn;\u0026thinsp;1.112\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAppropriate Assessment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e2.148\u0026thinsp;\u0026plusmn;\u0026thinsp;0.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e2.852\u0026thinsp;\u0026plusmn;\u0026thinsp;0.785\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eTwo groups underwent independent sample t-test comparison\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates a statistical difference\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e summarizes the course experience feedback of students in classroom teaching, mastery of basic skills, goals and standards, appropriate assignments, and appropriate assessments. Interestingly, there were significant differences in feedback between the two groups of students in various aspects.\u003c/p\u003e\u003cp\u003eCompared with traditional teaching classrooms, students believe that blended learning provides a better experience in classroom teaching (t\u0026thinsp;=\u0026thinsp;10.019, P\u0026thinsp;=\u0026thinsp;0.000), basic skill mastery (t\u0026thinsp;=\u0026thinsp;7.904, P\u0026thinsp;=\u0026thinsp;0.000), clear goals (t\u0026thinsp;=\u0026thinsp;4.674, P\u0026thinsp;=\u0026thinsp;0.000), appropriate homework (t\u0026thinsp;=\u0026thinsp;5.101, P\u0026thinsp;=\u0026thinsp;0.000), and appropriate assessment (t\u0026thinsp;=\u0026thinsp;4.530, P\u0026thinsp;=\u0026thinsp;0.000).\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 Traditional Teaching Group and Blended Teaching Group in the Learning Process\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTeaching methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraditional Teaching Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBlended learning group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeep Motivation(DM)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.669\u0026thinsp;\u0026plusmn;\u0026thinsp;0.386\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.312\u0026thinsp;\u0026plusmn;\u0026thinsp;0.183\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeep Strategy(DS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e4.676\u0026thinsp;\u0026plusmn;\u0026thinsp;0.340\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.352\u0026thinsp;\u0026plusmn;\u0026thinsp;0.194\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurface Motivation(SM)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.676\u0026thinsp;\u0026plusmn;\u0026thinsp;1.245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.384\u0026thinsp;\u0026plusmn;\u0026thinsp;0.199\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.007*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSurface Strategy(SS)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.655\u0026thinsp;\u0026plusmn;\u0026thinsp;1.279\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.432\u0026thinsp;\u0026plusmn;\u0026thinsp;0.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.004*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eTwo groups underwent independent sample t-test comparison\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical difference\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the comparison of students' deep motivation, deep strategy, surface motivation, and surface strategy in the learning process.\u003c/p\u003e\u003cp\u003eThe traditional teaching group outperformed the blended learning group in terms of deep motivation (t\u0026thinsp;=\u0026thinsp;4.257, P\u0026thinsp;=\u0026thinsp;0.000) and deep strategy (t\u0026thinsp;=\u0026thinsp;4.208, P\u0026thinsp;=\u0026thinsp;0.000). The blended learning group outperformed the traditional teaching group in terms of surface motivation (t\u0026thinsp;=\u0026thinsp;2.810, P\u0026thinsp;=\u0026thinsp;0.007) and surface strategy SS (t\u0026thinsp;=\u0026thinsp;2.991, P\u0026thinsp;=\u0026thinsp;0.004).\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\u003eFeedback from Trainee Teachers in Traditional Teaching Group and Blended Teaching Group\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=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eTeaching methods\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eP value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTraditional Teaching Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBlended learning group\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe lecture greatly enhanced students' understanding of this topic.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.130\u0026thinsp;\u0026plusmn;\u0026thinsp;0.619\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.750\u0026thinsp;\u0026plusmn;\u0026thinsp;0.447\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe course met my expectations.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.190\u0026thinsp;\u0026plusmn;\u0026thinsp;0.544\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.560\u0026thinsp;\u0026plusmn;\u0026thinsp;0.512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIt is an enjoyable way of teaching.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.500\u0026thinsp;\u0026plusmn;\u0026thinsp;0.516\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.690\u0026thinsp;\u0026plusmn;\u0026thinsp;0.479\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOverall, I am satisfied with the quality of this course.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.500\u0026thinsp;\u0026plusmn;\u0026thinsp;0.516\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.630\u0026thinsp;\u0026plusmn;\u0026thinsp;0.619\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe climate of this class is conducive to learning for students.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e\u003cp\u003e3.440\u0026thinsp;\u0026plusmn;\u0026thinsp;0.512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e\u003cp\u003e4.560\u0026thinsp;\u0026plusmn;\u0026thinsp;0.512\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.000*\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eTwo groups underwent independent sample t-test comparison\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicates statistical difference\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the feedback from two groups of trainee teachers, the traditional teaching group and the blended learning group. Compared with traditional teaching methods, more teachers believe that blended learning can improve students' understanding of learning content (t\u0026thinsp;=\u0026thinsp;8.510, P\u0026thinsp;=\u0026thinsp;0.000), meet their expectations (t\u0026thinsp;=\u0026thinsp;7.361, P\u0026thinsp;=\u0026thinsp;0.000), and is a pleasant teaching method (t\u0026thinsp;=\u0026thinsp;6.746, P\u0026thinsp;=\u0026thinsp;0.000). They are more satisfied with the quality of blended classrooms (t\u0026thinsp;=\u0026thinsp;5.582, P\u0026thinsp;=\u0026thinsp;0.000), and the class atmosphere is more conducive to students' learning (t\u0026thinsp;=\u0026thinsp;6.211, P\u0026thinsp;=\u0026thinsp;0.000).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn addition, most teachers believe that corneal refractive surgery is a more suitable topic for a blended learning mode (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003eA), which can be conducted once a week during probationary teaching (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003eB).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study is the first to evaluate the effectiveness of a blended clinical practice model based on MOOC and digital twin technology in the teaching of optometry. The study found that this blended teaching model got better teaching results and was loved by the participating teachers and students.\u003c/p\u003e\u003cp\u003eSeveral factors potentially explain these outcomes:\u003c/p\u003e\u003cp\u003e(1) Enhanced Cognitive Engagement. The blended clinical internship model integrates MOOC-based tasks with digital twin-simulated surgical procedures, fostering deeper student immersion. This synergy promotes profound conceptual understanding and procedural mastery\u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e, while concurrently developing proactive problem-solving skills. Consequently, students demonstrate improved academic performance and clinical reasoning, facilitating deeper learning processes\u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e(2) Learner-Centered Design. Emphasizing learner autonomy, the blended clinical internship model accommodates personalized needs and interests through self-directed content selection. Integrated MOOC and digital twin technologies provide real-time performance analytics, enabling students to accurately identify knowledge gaps and dynamically optimize learning strategies. This metacognitive feedback loop significantly enhances self-regulated learning capabilities and self-efficacy among graduate trainees\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e(3) Adaptive Learning Flexibility. The blended clinical internship model addresses inherent limitations of traditional didactic approaches\u0026mdash;such as attentional fragmentation and constrained review opportunities\u0026mdash;by incorporating on-demand video resources\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. Learners exert granular control over study schedules, locations, and repetition frequency, aligning instruction with individual cognitive preferences. This inherent adaptability ensures educational responsiveness to rapidly evolving healthcare demands\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e(4) Theory-Practice Integration and Enhanced Interactivity. The model systematically bridges theoretical knowledge with clinical application, enabling iterative reinforcement through simulated practice\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Furthermore, its structured interactive framework facilitates timely instructor feedback and scaffolding support. These features collectively increase learning motivation, foster intrinsic engagement, and strengthen knowledge retention\u003csup\u003e[\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn summary, this study indicates that the blended clinical internship model is widely welcomed by medical students and can effectively improve their academic performance. This indicates that the blended clinical internship model may be a direction for the reform of internship teaching for optometry students.\u003c/p\u003e\u003cp\u003eBy observing the evaluation of the teaching process and teaching effectiveness, the blended clinical internship model based on MOOC and digital twin technology has significantly better short-term and long-term learning effects than traditional teaching methods. The experimental group has a sustained advantage in refractive classes, with the differences in their scores before, after, and at the end of the exam gradually widening. This indicates that students can gain a deeper understanding of procedural knowledge through the \"theory simulation practical\" framework that combines pre-course MOOC module learning with offline clinical practice. However, the small performance gap in amblyopia classrooms also highlights the limitations of blended learning in the experience dependent domain.\u003c/p\u003e\u003cp\u003eThe experimental group maintained a stable advantage in the final exam, indicating that the blended learning model not only enables students to master the basic knowledge required in teaching, but also significantly exercises their clinical thinking ability for ophthalmic optical diseases, truly cultivating students' comprehensive ability to analyze and solve practical problems \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. However, exam scores only reflect the level of theoretical mastery, and longitudinal research is needed to verify whether this model truly enhances decision-making ability in real clinical environments.\u003c/p\u003e\u003cp\u003eDespite the many benefits of blended learning, traditional instruction is more effective at fostering deep motivation and techniques (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This suggests that the benefits of both traditional teaching methods and blended learning may be able to be combined\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Furthermore, the soft skills acquired through blended learning could be overlooked by the present evaluation system, which is based on exam results. Multimodal indications, such peer evaluations and simulated clinical exams, can be added in the future to fully gauge students' aptitudes.\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis innovative and revolutionary teaching method demonstrates significant potential for broader educational applications in ophthalmic and optometric education as a proven instructional strategy.\u003c/p\u003e\u003cp\u003eThis approach significantly enhances technical skill acquisition and consistently improves short-term learning outcomes, as evidenced by multiple studies. However, the development of higher-order cognitive skills necessitates systematic integration with traditional didactic instruction \u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis educational paradigm bridges technological gaps in medical training, strategically redefines instructor roles to align with digital competencies, and establishes flexible, competency-based curriculum frameworks. Consequently, it fosters lifelong learning capacity in students, enabling them to adapt to rapidly evolving healthcare landscapes.\u003c/p\u003e\u003cp\u003eThis graduate-centered blended clinical internship model, integrating MOOC platforms with digital twin technology, leverages the synergistic effects of technological innovation and self-directed learning to transform traditional didactic approaches into an interactive, cognitively engaging, and clinically rich educational paradigm. Beyond cultivating capacities for autonomous learning, higher-order cognitive abilities, and practical clinical skills, it enables the flexible application of theoretical knowledge to disease diagnosis and treatment, establishing a robust foundation for evidence-based clinical practice\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSRT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003estandardized residency training\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMOOC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003emassive open online course\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eDT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003edigital twin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval was obtained from the Ethics Committee of the First Affiliated Hospital of Harbin Medical University. The procedures used in this study adhere to the tenets of the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare no competing interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch on the Hybrid Clinical Internship Model Based on MOOC and Digital Twin Technology in the Teaching of Ophthalmology and Optometry Graduate Students, General Research, 2022 [SJGY20220268]\u003c/p\u003e\n\u003cp\u003eResearch and Practice of Multidimensional Stereoscopic Teaching Mode Based on OBE Concept in the Cultivation of Ophthalmic Graduate Students, Key Project of the 14th Five Year Plan for Education Science in Heilongjiang Province in 2022 [GJB1422773]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Teaching preparation, student organization, data collection and analysis were completed by Yang Kang, Kanwen Wang, Jing Cui, Zidan Guo, Chenggong Jiang and Xue Li. The initial draft of the manuscript was written by Kanwen Wang, and all authors have commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026apos; information\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYang Kang\u003csup\u003e1#\u0026nbsp;\u003c/sup\u003e, Kanwen Wang\u003csup\u003e\u0026nbsp;2#\u003c/sup\u003e , Jing Cui\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e, Zidan Guo\u003csup\u003e\u0026nbsp;3\u003c/sup\u003e, Chenggong Jiang\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e, Xue Li\u003csup\u003e\u0026nbsp;1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e1 Eye Hospital, The First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang Province, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003e2 Harbin Medical University, Harbin, Heilongjiang Province, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003e3 Outpatient department of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province, People\u0026rsquo;s Republic of China.\u003c/p\u003e\n\u003cp\u003e# These authors contributed equally to this work.\u003c/p\u003e\n\u003cp\u003eCorrespondence: Xue Li,\u0026nbsp;Eye Hospital，The First Affiliated Hospital of Harbin Medical University, No. 143，\u0026nbsp;Yiman Street, Harbin, Heilongjiang Province 150001, China (e-mail:\u0026nbsp;[email protected]).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFootnotes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMORRISSEY B, HEILBRUN ME. 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Behav Sci (Basel), 2023, 13(2).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHUANG Z, YANG J, WANG H, et al. Integration of Massive Open Online Course (MOOC) in Ophthalmic Skills Training for Medical Students: Outcomes and Perspectives [J]. Asia Pac J Ophthalmol (Phila). 2022;11(6):543\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLEE Y, SONG HD. Motivation for MOOC learning persistence: An expectancy-value theory perspective [J]. Front Psychol. 2022;13:958945.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBALLOUK R, MANSOUR V. Medical students' self-regulation of learning in a blended learning environment: a systematic scoping review [J]. Med Educ Online. 2022;27(1):2029336.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMOON H, HYUN HS. Nursing students' knowledge, attitude, self-efficacy in blended learning of cardiopulmonary resuscitation: a randomized controlled trial [J]. BMC Med Educ. 2019;19(1):414.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eACOSTA ML, SISLEY A, ROSS J, et al. Student acceptance of e-learning methods in the laboratory class in Optometry [J]. PLoS ONE. 2018;13(12):e0209004.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDU L, ZHAO L, XU T, et al. Blended learning vs traditional teaching: The potential of a novel teaching strategy in nursing education - a systematic review and meta-analysis [J]. Nurse Educ Pract. 2022;63:103354.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKE L, XU L, SUN L, et al. The effect of blended task-oriented flipped classroom on the core competencies of undergraduate nursing students: a quasi-experimental study [J]. BMC Nurs. 2023;22(1):1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYU D Y, ZHANG L, LI YL et al. The Implementation of a MOOC-Based Flipped Classroom Teaching Method in the Context of Oncology Radiotherapy Residency Training [J]. J Cancer Educ, 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMIAO J, CHANG J, Teacher-Student MAL, Interaction. Student-Student Interaction and Social Presence: Their Impacts on Learning Engagement in Online Learning Environments [J]. J Genet Psychol. 2022;183(6):514\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWESTERLAKEN M, CHRISTIAANS-DINGELHOFF I, FILIUS R M, et al. Blended learning for postgraduates; an interactive experience [J]. BMC Med Educ. 2019;19(1):289.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eQUTIESHAT A S, ABUSAMAK M O, MARAGHA T N. Impact of Blended Learning on Dental Students' Performance and Satisfaction in Clinical Education [J]. J Dent Educ. 2020;84(2):135\u0026ndash;42.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJUHI A, PINJAR M J, MARNDI G, et al. Evaluation of Blended Learning Method Versus Traditional Learning Method of Clinical Examination Skills in Physiology Among Undergraduate Medical Students in an. Indian Med Coll [J] Cureus. 2023;15(4):e37886.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDE JONG P G M, HENDRIKS R A, LUK F, et al. Development and application of a massive open online course to deliver innovative transplant education [J]. Transpl Immunol. 2021;66:101339.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLIAO W, HE J, YANG C, et al. Application of a new multi-element integrated teaching mode based on bite-sized teaching, flipped classroom, and MOOC in clinical teaching of obstetrics and gynaecology [J]. BMC Med Educ. 2023;23(1):820.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCOGAN E, MAISONNEUVE H, LEEMAN M, et al. [How to formalise the supervision of learning of clinical reasoning] [J]. Rev Med Interne. 2020;41(8):529\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBARBAGALLO MS, PORTER J E LAMUNUM. Evaluation of a Blended Online and Digital Learning Mode of Anatomy and Physiology for Undergraduate Nursing Students [J]. Comput Inf Nurs. 2020;38(12):633\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":"Blended learning, optometry, Master education, Self-directed learning ability, Self-efficacy","lastPublishedDoi":"10.21203/rs.3.rs-7042220/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7042220/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eIn optometry education, insufficient theoretical depth and limited practical opportunities during clinical rotations contribute to gaps in theoretical knowledge and operational skills. While MOOCs offer flexible resource integration and digital twin technology provides high-fidelity simulation, standalone applications have limitations. This study therefore evaluated the effectiveness and acceptability of a novel MOOC-digital twin hybrid clinical internship model in optometry, specifically assessing its impact on students' theoretical mastery, clinical operational ability, and comprehensive learning experience, to provide empirical evidence for educational reform.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eFifty-four ophthalmology graduate students were divided into an experimental group and a control group. The experimental group utilized the MOOC platform for pre-class theoretical learning and employed digital twin technology to simulate corneal refractive surgery procedures. The control group received traditional classroom lectures and demonstrations. Learning outcomes were compared using in-class tests, final subject assessments (theoretical and practical), and questionnaires. Data were analyzed using independent samples t-tests.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe experimental group achieved significantly higher scores in both refractive surgery (pre-test: t\u0026thinsp;=\u0026thinsp;4.096, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; final exam: t\u0026thinsp;=\u0026thinsp;3.642, P\u0026thinsp;=\u0026thinsp;0.001) and amblyopia modules (t\u0026thinsp;=\u0026thinsp;2.33, P\u0026thinsp;=\u0026thinsp;0.024), with progressive improvement over time. They also reported superior teaching satisfaction, task-clinical relevance, and course interest (all P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Instructors (92%) noted enhanced student comprehension and improved learning climate (t\u0026thinsp;=\u0026thinsp;6.211, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003eThe MOOC-digital twin hybrid mode, structured around a \"theory \u0026rarr; simulation \u0026rarr; practice\" framework, effectively synergizes the flexibility of MOOCs with the practical realism of digital twins, significantly enhancing students' active learning capabilities and clinical reasoning in optometry training. This study provides empirical support for the model's efficacy as a tool for medical education innovation.\u003c/p\u003e","manuscriptTitle":"The blended clinical internship model based on MOOC and digital twin technology in optometry teaching","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-11 09:59:08","doi":"10.21203/rs.3.rs-7042220/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-12T12:22:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T17:40:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-21T07:17:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"16064063718399237816169592038973986764","date":"2025-10-19T04:23:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"43660051643448344076405666883671013404","date":"2025-10-17T06:30:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"129940995568025906308221604322314714620","date":"2025-09-20T02:45:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123448734229538872338938177233871988796","date":"2025-08-09T19:43:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-05T16:34:08+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-16T13:47:16+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-11T09:49:47+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-11T09:48:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Education","date":"2025-07-04T02:10:00+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":"cc6b379f-3b1c-4c48-9044-f6c2d0544e7a","owner":[],"postedDate":"August 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-03T05:08:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-11 09:59:08","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7042220","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7042220","identity":"rs-7042220","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}