Problem/case-based learning with competition introduced in severe infection education: an exploratory study
Lei et al. SpringerPlus
Problem/case-based learning with competition introduced in severe infection education: an exploratory study
Jian‑Hua Lei 0 2
YiJ‑ing Guo 1
Zi Chen 0 2
YaoY‑an Qiu 1
Guo‑Zhong Gong 0 2
Yan He 0 2
0 Department of Infectious Diseases, The Second Xiangya Hospital, Central South University , No. 139 Middle Renmin Road, Changsha 410011, Hunan , People's Republic of China
1 EightY‐ear Clinical Medicine , 2010 Grade , Xiangya School of Medicine, Central South University , No. 172 Tongzipo Road, Chang‐ sha 410013, Hunan , People's Republic of China
2 Department of Infectious Diseases, The Second Xiangya Hospital, Central South University , No. 139 Middle Renmin Road, Changsha 410011, Hunan , People's Republic of China
Background: Problem/case‑ based learning (PCBL) is one of the most commonly used educational methods in medical schools. Aim: To further improve PCBL in clinical course of severe infection by introducing competition mode. Methods: Two classes of medical students were divided into two groups by class‑ based simple randomization and were taught the course of severe infection by PCBL. A team‑ based competition was introduced in the study group (n = 35) while not in the control group (n = 36). After the course, four closely associated references were recommended. All the students were notified about a group consultation on a similar case. In the final examination, a case with severe infection complicated with infectious shock was presented for the students to analyze and resolve listed questions. Their performances were qualitatively evaluated to justify the effectiveness of the competition‑ based PCBL. Results: The students in the study group were more active and initiative in case discussion and interaction, in referring to case‑ related articles and attending clinical group‑ consultation. They had better performance in the case analysis in the final examination. The typical case analysis test easily figured out more excellent students in the study group. Conclusions: The PCBL with competition mode introduced in is an effective approach to guide students to fully understand the clinical diagnoses and treatment of severe infection. It also prompts medical students' initiative in referring to case‑ related articles and attending group‑ consultation, both of which are essential to equip medical students with sufficient competency for clinical practice.
Problem/case‑ based learning; Competition mode; Clinical course; Severe infection
Learning is a process which results in some changes or
modifications in the learners’ ways of thinking, feeling
and doing. The medical undergraduates mainly achieve
their knowledge and skills through theoretical teaching
and clinical practice. A very significant method in
testing the teaching effect of medical education is to
evaluate students’ basic ability including both the capability
to make diagnoses and the practical ability to implement
the treatment plans.
Medical courses used to be taught in traditional
education approaches by means of tutorials, didactic lectures
and practical classes. They are teacher-centered, with
minimal active participation from the students, leading
to lack of critical thinking in students and insufficient
training targeted at integrating skills (Zahid et al. 2016).
Critical thinking is of great importance to physicians’
evolving clinical expertise (West et al. 2000). Its
development needs an education system featured by a
studentcentered process. In this process, the teacher is hoped
to use various innovative teaching methods to get the
students motivated for meaningful learning rather than
just passively receiving information, to get them actively
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participate in the process of learning and prepare
themselves for a lifelong self-directed learning.
Problem-based learning (PBL) is a student-centered
pedagogy in which students learn through solving listed
questions. In PBL, students focus on complex
problems without standard answers. They work in
collaborative groups to identify what they need to learn in order
to solve these problems (Tyler et al. 2009). The student
is inculcated with capabilities to work productively as
a team member, to master communication skills, to
develop better clinical reasoning skills and presentation
skills, to make decisions in unfamiliar situations, and to
respect others, which are all key areas of a student’s
education in community medicine (Schwartz et al. 1997;
Khan and Fareed 2001). PBL encourages critical
thinking, independent responsibility for learning,
knowledge acquisition, sharing information, effective time
management and better retention of information. It
thus stimulates higher-order learning and helps achieve
high professional competency (Wood 2008; Schwartz
et al. 1997). Students in PBL classes have higher
attendance and academic performance (Peters et al. 2000). The
PBL approach to learning in medical education is the
most significant educational innovation in the past four
decades. Medical students learning by PBL approach
obtained significantly higher knowledge and skill scores
(Meo 2013), had increased learning and recalling output
(Imanieh et al. 2014), excellent academic performance
and higher success rates in examinations (Joseph et al.
2016), enhanced problem-solving skills and analytic skills
(Shamsan and Syed 2009), as well as outstanding clinical
reasoning skills (Tayyeb 2012). They were better at
integrating basic science knowledge with clinical cases (Callis
et al. 2010).
Case-based learning (CBL) is another popular
studentcentered teaching method. In the CBL, an authentic
clinical case is given as a stimulus. The teacher is no longer a
lecturer but a guider leading the process instead of giving
the information directly. Exposing students to complex
clinical cases promotes self-directed learning, clinical
reasoning, clinical problem-solving and decision making.
CBL generated the medical students’ learning
enthusiasm, facilitated the health professionals’ deeper
conceptual understanding, improved nursing students’ patient
assessment skills and fostered more active and
collaborative learners (Zhang et al. 2012; Thistlethwaite et al. 2012;
Raurell-Torredà et al. 2015; Nordquist et al. 2012).
As a combination of CBL and PBL,
problem/casebased learning (PCBL) has all of their advantages. PCBL
can prompt students to develop team spirit in study and
foster competitive learning mode and deep
understanding of the knowledge relevant to teaching contents. PCBL
has some other advantages including improving learning
ability and other skills, encouraging self-assessment and
logical thinking, integrating theory with practice, and
developing students’ personalized learning by arousing
internal and external enthusiasm (Aljarallah and Hassan
2015). Nowadays, PCBL is gradually becoming popular in
medical education all over the world.
In spite of all these merits, doubts towards the
effectiveness of PBCL existed (Carrero et al. 2007, 2008).
So a new booster was needed. Based on the facts that
team-based competition could increase resident
physicians’ participation in quality-improvement education
(Scales et al. 2016) and enhance weight loss outcomes
(Leahey et al. 2012), a competition based PCBL teaching
approach was tried.
In the selection of the teaching cases in PCBL, we
focused on cases with severe infections, for severe
infection is a difficult chapter in the clinical courses of
infectious diseases for teaching. In the past, teaching of
the infectious diseases almost all followed the hints of
etiological and epidemiological characteristics, clinical
manifestations, laboratory tests, diagnosis and
differential diagnosis, treatment and prevention of the
diseases. Selection of the representative clinical cases in
the CBL courses and guiding question lists in the PBL
courses both followed the same regime. However, the
pathogens leading to severe infections are generally
unidentified, so in practice, judgment on the progress
and treatment of a disease are taught from the
perspectives of changes of the patient’s condition and its
underlying pathophysiological mechanisms. That is, it
can’t be taught in the same approach for a traditional
infectious disease with a definite pathogen. A
casebased and problem-driven teaching approach is
essential to cultivate and mobilize clinical thinking of the
medical student and to help them to develop a broader
perspective of case scenarios.
Based on the above considerations, we introduced
competition into PCBL in the teaching of severe
infection to hope for better teaching effects. This study was
hence done to compare the academic and clinical
performance of students taught severe infections by
competition based-PCBL methodology with that of students by
regular PCBL method.
Infectious Diseases published in 2010 by the People’s
Medical Publishing House of People’s Republic of China
was used as the textbook. And the multimedia teaching
courseware was made by the same crew of the
Department of Infectious Diseases, the Second Xiangya
Hospital, Central South University. The courses were taken in a
classroom and lasted for 2 h.
Teaching subjects and management
We recruited seventy-one students from two classes of
the same major who were studying clinical courses and
on probation in the Department of Infectious Diseases,
the Second Xiangya Hospital, Central South University.
They all had completed the 3-year education on basic
medicine and half a year-basic education of clinical skills.
The students were divided into two groups by class-based
simple randomization. The ratio of males to females was
balanced between the two groups. All of the students
were taught the same course of severe infection by PCBL.
The students in the study group (n = 35) were divided
into five teams and taught by competition-introduced
PCBL. The students in the control group (n = 36) were
taught in a regular PCBL way. The teaching approaches
for the other chapters of infectious diseases and the
related probation practice were the same for both groups.
Teaching case and listed questions
The medical history of the case used in the teaching
course was as follows. A middle-aged male had diabetes
for several years and did not have a good control of blood
glucose. A community general physician treated him
inadequately when he suffered from a slight infection in
late February, 2014. Then the infection developed into a
severe Klebsiella pneumoniae sepsis with multiple organ
dysfunction syndrome (MODS), infectious shock and
liver migrating abscesses (see Fig. 1). After correct
clinical and etiological diagnoses in our hospital, the patient
received proper treatment and finally recovered.
The 16 guiding questions for the PCBL teaching were
listed below. They were about the incentive, etiology,
pathogenesis, clinical and etiological diagnoses and
prognosis of severe infection and principles for treatment of
infections, complications and infectious shock.
(A) What are the clinical features of a fever caused by an
(B) Are the treatment measures by the community
eral physician reasonable?
(C) What are the common causes of severe infections?
(D) If you had received the patient when he was
transferred to your hospital, what kinds of first aid
treatment would you prescribe?
(E) The patients had clinical manifestations of a shock.
Please describe the clinical classifications of shock
according to its etiology. What kind of shock was the
patient complicated with?
(F) What are the common pathogens associated with
(G) Epidemic hemorrhagic fever is endemic in Hunan
Province in later February. So what clinical hints
conduce to excluding the probability of epidemic
hemorrhagic fever in this case?
(H) What are the molecular mechanisms of infectious
shock induced by severe infections?
(I) Could you list some up-to-date biomarkers
conducive to the early diagnosis of a severe infection and
the subsequent infectious shock?
(J) Please describe the hemodynamic characteristics of
severe infections and subsequent infectious shock.
(K) Why metabolic acidosis and hyponatremia often
occur in patients suffering from infectious shock?
(L) Please list the treatment principles of infectious
shock according to its hemodynamic characteristics
and analyze the principles of early fluid resuscitation
and application of vasoactive agents.
(M) Many patients have stress hyperglycemia in
infectious shock. A great variety of clinical researches
propose sustained monitoring and control of the
blood glucose of the patients with severe infections.
When multiple tests find increased blood glucose
levels and strongly positive results in uric glucose
tests, how to identify their origin from stress
hyperglycemia or from diabetes?
(N) Opportunistic infections are common in diabetic
patients. What is the mechanism of
immunocompromise in them?
(O) Many retrospective clinical researchers have found
that for the diabetic patients complicated with
Klebsiella pneumoniae sepsis, especially when there are
obvious lung infection foci, there is a great possibility
of missed diagnosis of liver abscess. Could you
delineate the possible reasons and preventive measures
from the view of a clinical doctor?
(P) Please list several main mechanisms of drug
ance of resistant Klebsiella pneumoniae.
The study group was divided into five teams. The listed
16 case-relevant questions were classified into two
categories, required questions and quick response questions.
Each team answered the required questions in turn.
When one team answered the required questions, their
performance was marked by the other teams and
teachers. Before answering questions or evaluating answers,
the teams were given 5 min for full discussion among
team members. Interactive behavior like summarizing,
challenging and evaluating was encouraged within
confined time. All of the teams were given adequate time
to answer questions or rate other teams’ performance.
In the end, one team was judged to be the winner and
awarded in view of the integrity and accuracy of their
answers as well as the objectivity and equity of their
Fig. 1 Computed tomography (CT) examination results of the teaching case. a Before CT‑ guided percutaneous aspiration and catheter drainage
in the management of liver abscesses. b Three months after CT‑ guided percutaneous aspiration and catheter drainage in the management of liver
scoring practice. Two cinema tickets were provided for
each winner as an award.
All statistical analyses were performed with IBM®
SPSS® Statistics version 20.0, using descriptive statistical
indexes such as rate, ratio, mean and standard deviation
(SD), et al. Chi squared test was performed for
comparison of rates and ratios. Analysis of Variance (ANOVA)
and Kruskal–Wallis H test were performed for
comparison of means. One sample Kolmogorov–Smirnov test
was used to verify the normal distribution of data sets.
For all these tests, P value less than 0.05 was considered
Participation in discussion and interaction in the course
The person-times and constitutions of the students
participating in discussion, answering questions initiatively
and further challenging or analyzing others’ answers
were all significantly higher in the study group than in
the control group (see Table 2). The overall person-times
and constitutions of the students participating in
interaction actively were also statistically different (χ2 = 29.762,
P = 0.000).
Performance in referring to the references provided
Totally, 51.4 % (18/35) of the students in the study group
referred to the references provided by the teachers on
their own initiative, and the proportion was
significantly higher than that in the control group (13.9 %, 5/36,
χ2 = 11.419, P = 0.001). The average pieces of articles
Table 1 Assessment of teaching efficiency
Participation in discussion and interaction
Initiative in referring to articles
Initiative in participating in a group consultation
Performance in a case analysis in the final examination
The number of the students participating in discussion and interaction for each question
was recorded and their participation degree was described as participation person‑times.
For example, for Question 1, 8 students participate in discussion, 3 answer questions and 4
challenge others’ answers, then the group’s participation in Question 1 was 15 person‑times.
The participation person‑times for each question are summed up to get the overall person‑
times for the teaching course
After the course, a list of four referable articles closely associated with the case, including
international guidelines for management of severe sepsis and septic shock composed
by the Surviving Sepsis Campaign Guidelines Committee, were provided to the students
in both groups. Two weeks after the course, the number of the students referring to the
recommended articles and the number of the articles referred to by each student were
Within 2 weeks after the course, all the students were notified that a group consultation on
a similar case with severe infection would be held in the infection wards, and they could
participate in it on their own initiative. The proportion of the students participating in the
consultation in each group was calculated
At the end of the semester, the participants were assigned a task in the final examination
without prior notice to analyze a case with severe infection and infectious shock, to make
a diagnosis and a clinical treatment scheme. The scoring rates of correct diagnoses and
proper clinical treatments were calculated. For example, 10 key points were delineated for a
full answer for the correct diagnosis, and the students listed 7 points, then the scoring rate
of the student for the diagnosis was expressed as 0.7. Besides, the discrimination value in
this case analysis was analyzed. All the indicators listed above were compared between the
study group and control group for evaluating the teaching effectiveness
read by the students initiatively in the study group were
also significantly higher (0.85 ± 0.97 vs. 0.25 ± 0.69,
Kruskal–Wallis H test, χ2 = 10.431, P = 0.001).
Attendance in group consultation
Totally, 25.7 % (9/35) of the students in the study group
attended the group consultation initiatively, while only
5.6 % (2/36) did in the control group, with statistically
significant difference (χ2 = 4.076, P = 0.043).
Performance in the clinical case analysis in the final
The rates of correct diagnoses and of the correct answers
to the listed questions about key points in clinical
treatment of infectious diseases in the final examination were
compared between the two groups.
The scoring rate in the case analysis was neither high
in the study group (0.62) nor in the control group (0.51),
which conformed to the characteristics of the
medical students who didn’t enter the internship phase. The
scores of the students in the study group who had the
competition mode were significantly higher (P < 0.05).
So were the rates of correct diagnosis (74.3 vs 58.3 %)
and correct answer to the critical points in clinical
handling of patients with severe infection (65.6 vs 44.8 %)
(P < 0.01) (see Table 3).
Discrimination value of the case analysis test in the
For the students in the study group who were taught by
the competition mode, the scoring rates of the case
analysis in the students with total score ranking within the
top 27 % and within the last 27 % in the infectious
disease final examination were 86.3 and 50.0 % respectively,
and the discrimination value was 0.36. As for the
students in the control group without competition mode,
the scoring rates of the case analysis in the students with
total score ranking within the top 27 % and within the
last 27 % in the infectious disease final examination were
65.3 and 43.3 % respectively, and the discrimination
value was 0.22 (see Table 4). It indicated that such
typical case analysis was more suitable for testing the
clinical competence of the students actively participating in
Medical graduates today are facing numerous emerging
diseases and are particularly expected to be critical
thinkers and self-directed learners. They are supposed to have
generic skills like effective communication and teamwork
besides problem-solving ability in activities including
making disease diagnosis, formulating treatment
strategies and investigating epidemics.
Question Study group (n = 35)
Table 2 Comparison of the person-times of participation in discussion and interaction for each question and the total
between two groups
chalquestions initia- lenging or
anatively lyzing others’
Control group (n = 36)
Supposed total person-times for each question for each group = 3 × n
Supposed total person-times for all the questions for each group = 3 × 16 × n
a Comparison between 15/(3*35) for the study group and 6/(3*36) for the control group
b Comparison between 192/(3*16*35) for the study group and 108/(3*16*36) for the control group
Table 3 Comparison of the rates of correct diagnoses and of correct answers to listed questions about key points
in clinical treatment of infectious diseases in the final examination between two groups
Table 4 Discrimination value for excellent students in the
infectious disease final examination by a case analysis test
Study group (n = 35)
Study group (n = 35)
Control group (n = 36)
World Health Organization (WHO) consultations
on public health teaching and training recommend
student-centered, inquiry-driven, problem-oriented and
evidence-based innovative learning methods in public
health courses. The teacher was expected to teach
students by student-centric and problem-based approaches,
playing a role as a facilitator to help students to acquire
these competencies (WHO 2010).
PCBL, a teaching mode innovation totally different
from one-way indoctrination classes in the traditional
teaching, meet the needs.
In our study, a further step was taken. A competition
mode with two cinema tickets as an award was
introduced into the PCBL, which did improve the teaching
efficacy. Despite the motivation by the award, the
winners were more moved by the sense of achievements. The
students taught by competition—based PCBL approach
devoted themselves more in the discussion and
interaction in the course. They were more active and initiative in
referring to the case-related articles and in participating
in the clinical group-consultation. Both practices were
essential to cultivate the students’ comprehensive
ability to cope with diagnosis and treatment of complicated
cases, and also conducive to helping them to develop a
habit to effectively integrate research articles with
clinical practice. In the final examination, these students had
a better performance. They had a higher rate of correct
diagnoses as well as higher scores than the controls.
Competition introduced PCBL could motivate the
students to think more actively and deeply and fostered
more excellent students than the regular PCBL.
Sense of self-respect and desire for winning are
characteristics of the students at college age, which enables the
competition mode as an important promoter. Besides,
dividing the group into several teams could initiate more
communications and inspirations. The competition mode
inspired students’ interest and enabled them to focus on
the cases and listed questions and to recall and integrate
related knowledge to interpret the cases and solve the
problems. The practice of comparing the answers of
students with teachers emphasized the significance of
clinical experience and practice. Moreover, different forms of
competition gave everyone the chance to demonstrate their
competency. Despite some critical overview on the
effectiveness of PBL and CBL in medical education (Al-Azri and
Ratnapalan 2014; Chilkoti et al. 2014), students preferred
to problem-based learning over lecture-based learning
because of motivation boost, knowledge retention, class
attractiveness and practical use (Joseph et al. 2016).
Based on the results of our study, PCBL with
competition mode introduced in medical teaching conduces to
development of clinical reasoning, critical thinking and
self-directed learning skills and helps in developing a
broader perspective of case scenarios. It is proposed to
be applied in the teaching of medical science. Popular use
of Electronic Healthcare Record (EHR) in hospitals
provided a large database for selection of real patient stories
as educative cases Ricci et al. 2016).
As for colleges and universities other than medical
ones, to maximize the effectiveness of PBL, PBL curricula
should be revised according to their own needs. Taking
the characteristics of different subjects into full
consideration, better alignment between PCBL and the
reigning teaching and learning regime, frequent check the
weaknesses of the implementation process and
promotion of the future use of the checklist are key to
successful implementation of PCBL in medical undergraduate
The PCBL with competition mode introduced in is an
effective approach to guide medical students to fully
understand the clinical diagnoses and treatment of severe
infection. It also prompts medical students to initiatively
and consciously refer to case-related articles and
participate in related group-consultation, both of which are
essential to equip medical students with competency
sufficient to face clinical practice.
PBL: problem‑based learning; CBL: case ‑based learning; PCBL: problem/
case‑based learning; WHO: World Health Organization; MODS: multiple organ
dysfunction syndrome; ANOVA: analysis of variance; EHR: electronic healthcare
record; CT: computed tomography.
J‑HL and ZC designed the teaching mode, G‑ZG and YH organized the teach‑
ing of the courses and its assessment, ZC and Y‑ YQ analyzed the data, J‑HL and
Y‑ JG drafted the manuscript, G‑ZG and ZC participated in paper modification
and revised the manuscript for English writing, all authors participated in
critical revision of the manuscript. All authors read and approved the final
The research on teaching innovation and teaching interaction in infectious
diseases education were strongly supported by the management office of the
Eight‑ year Clinical Medicine, 2010 grade, Xiangya School of Medicine, Central
The authors declare that they have no competing interests.
Availability of data and materials section
The datasets supporting the conclusions of this article are included within
the teaching portfolios of the Department of Infectious Diseases, the Second
Xiangya Hospital, Central South University.
Design of the study and collection, analysis, and interpretation of data and the
manuscript writing and publishing were funded by the Department of Infec‑
tious Diseases, the Second Xiangya Hospital, Central South University.
Institutional review board
The study was reviewed and approved by the Review Board of the Second
Xiangya Hospital, Central South University.
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