Impact of Flipped Classroom Combined with Mini-CEX Formative Assessment on Core Competencies in Undergraduate Endocrinology Education: A Randomized Controlled Trial

Technical Summary: Impact of Flipped Classroom Combined with Mini-CEX Formative Assessment on Core Competencies in Undergraduate Endocrinology Education

Problem Statement
Traditional lecture-based instruction in undergraduate endocrinology education often fails to cultivate the multidimensional core competencies required by modern medical curricula, such as clinical reasoning, self-directed learning, and professionalism. While active learning strategies like the flipped classroom and workplace-based assessment tools like the Mini-Clinical Evaluation Exercise (Mini-CEX) have shown promise individually, their synergistic effect within a unified instructional model for preclinical undergraduate education remains underexplored. Furthermore, existing research often focuses on single-dimensional outcomes (e.g., exam scores) rather than comprehensive assessments of higher-order competencies.

Methodology
The study was a single-center, prospective, two-arm randomized controlled trial (RCT) conducted at the Department of Endocrinology, The First Affiliated Hospital of Bengbu Medical University, between June 2024 and March 2026.

• Participants: 120 third-year clinical medicine undergraduates were enrolled and randomly allocated (1:1 ratio) to an intervention group ($n=60$) or a control group ($n=60$). After exclusions for attendance, 57 students in the intervention group and 58 in the control group completed the study.
• Intervention:
  • Control Group: Received conventional didactic lectures (90 minutes) supplemented by Q&A, with no structured formative assessment.
  • Intervention Group: Participated in a blended "flipped classroom" model integrated with Mini-CEX. The cycle included: (1) Pre-class: Self-directed learning via video lectures, reading, and online quizzes; (2) In-class: Instructor-led summaries, small-group case discussions, and peer questioning; (3) Post-class: One-on-one Mini-CEX assessments covering seven competency dimensions (medical interviewing, physical examination, clinical judgment, counseling, organization/efficiency, humanistic qualities/professionalism, overall competence) with immediate structured feedback.
• Outcomes:
  • Primary: Theoretical examination scores and Objective Structured Clinical Examination (OSCE) scores.
  • Secondary: Mini-CEX dimensional scores, Self-Directed Learning Readiness Scale (SDLRS) scores, Critical Thinking Disposition Inventory (CTDI-CV) scores, and teaching satisfaction.
• Analysis: Statistical analysis utilized independent-samples t-tests, Mann-Whitney U tests, paired-samples t-tests, and repeated-measures ANOVA to evaluate group differences and time interactions.

Key Results

• Academic Performance: The intervention group achieved significantly higher scores in both the theoretical examination ($84.7 \pm 7.3$ vs. $79.8 \pm 8.1$, $P < 0.001$) and the OSCE ($85.9 \pm 6.8$ vs. $80.5 \pm 7.6$, $P < 0.001$) compared to the control group. Significant OSCE improvements were noted in history taking, clinical reasoning, and patient counseling, though physical examination scores did not reach statistical significance.
• Competency Development:
  • Mini-CEX: The intervention group showed significant improvements from the first to the final encounter in medical interviewing, clinical judgment, counseling, physical examination, and organization/efficiency. Improvements in "humanistic qualities and professionalism" were modest and not statistically significant.
  • Self-Directed Learning: The intervention group demonstrated a significantly greater increase in SDLRS total scores ($P < 0.001$), with specific gains in self-management, desire for learning, and self-control.
  • Critical Thinking: The intervention group showed a significant increase in CTDI-CV total scores ($P = 0.011$), particularly in analyticity, inquisitiveness, and self-confidence. No significant differences were found in open-mindedness, systematicity, truth-seeking, or cognitive maturity.
• Satisfaction and Workload: Students in the intervention group reported significantly higher satisfaction regarding learning interest, clinical thinking, communication skills, and feedback usefulness. However, they also perceived a significantly heavier study workload compared to the control group ($P = 0.009$).

Significance and Claims
The authors claim that this study represents one of the first RCTs to systematically evaluate the combined effect of a flipped classroom and Mini-CEX formative assessment on multidimensional core competencies in undergraduate endocrinology. The study concludes that this integrated pedagogical model significantly enhances theoretical knowledge, clinical skills, self-directed learning readiness, and critical thinking disposition compared to traditional instruction.

The authors position the findings as evidence that the flipped classroom is not limited to advanced clinical training but is effective in preclinical undergraduate cohorts. They highlight the value of Mini-CEX as a developmental tool that reinforces a "learning, practice, assessment, feedback" cycle. However, the authors maintain a modest tone regarding the limitations, acknowledging that the study was single-center, unblinded for participants/instructors, and lacked long-term retention data. They explicitly state that while the model improves many competencies, the increased workload requires optimization in future implementations, and that certain affective competencies (e.g., professionalism) and deep cognitive dispositions may require longer intervention periods to develop measurably.