Meta-analysis links integrated exam teaching to better internship outcomes in China

A systematic review and meta-analysis of 15 studies involving 4,182 participants found that traditional management of postgraduate entrance examination preparation was associated with reduced clinical-internship attendance and lower theoretical and practical-skill scores among medical students in China. By contrast, integrating the examination syllabus with case-based learning was associated with higher theoretical scores, better clinical-skill performance and higher postgraduate entrance examination success rates. The authors cautioned that the pooled results came from low-to-moderate quality studies with substantial statistical heterogeneity, making the findings hypothesis-generating rather than definitive.

The review examined evidence on the relationship between postgraduate entrance examination preparation, or PGEE, and clinical internship. The main PGEE review period in China overlaps with the clinical-internship phase of medical training, creating a potential conflict between examination preparation and participation in clinical activities. The review describes concerns in which examination preparation receives excessive emphasis, students are absent from internships, and opportunities to develop clinical skills become inadequate. Clinical internship is described as a central link between medical theory and practice, with a role in building clinical competence. Under traditional management models, the available evidence associated PGEE preparation with lower attendance and lower theoretical and practical clinical-skill scores.

Researchers followed PRISMA guidelines and searched the Cochrane Library, PubMed, EMbase, CNKI, Wanfang and VIP from their inception through 14 April 2026. Studies investigating the relationship between PGEE and clinical internship were eligible when they contained relevant quantitative data. Two researchers independently extracted data and assessed study quality. The Cochrane Risk of Bias 2 tool was used for randomized controlled trials, while the Newcastle-Ottawa Scale was applied to non-randomized studies. Meta-analysis was conducted in RevMan 5.4, and a random-effects model was used for all pooled estimates because heterogeneity was anticipated. The evidence therefore combines results reported across different study designs, and the authors’ conclusion should not be read as proof that integrated teaching will produce identical effects in every setting.

For the three outcomes with reported pooled estimates, integrated teaching produced more favorable results. Combining case-based learning, or CBL, with the PGEE syllabus was associated with a mean difference of 4.60 points in theoretical scores compared with the approaches evaluated in the included studies, with a 95% confidence interval of 3.37 to 5.83. The corresponding pooled association for clinical skills was a standardized mean difference of 1.24, with a 95% confidence interval of 0.73 to 1.75. For PGEE success rates, the pooled relative risk was 1.48, with a 95% confidence interval of 1.19 to 1.84. All three associations were statistically significant at P less than 0.05. These results support the review’s central interpretation that PGEE preparation and clinical internship are not inherently contradictory: aligning the teaching content may help students address examination requirements while continuing to develop clinical abilities.

Variation among the underlying studies limits the certainty of those estimates. Statistical heterogeneity was high for the theoretical-score result, with I² of 83.6%, and for clinical-skill performance, with I² of 91.2%. Heterogeneity was lower for PGEE success rates but remained present at I² of 51.4%. In addition, the pooled estimates were derived from studies of generally low-to-moderate methodological quality, creating a risk that the apparent benefits have been overestimated. The authors classify the findings as hypothesis-generating and as a reference for designing future high-quality investigations rather than as definitive practice recommendations. They state that validation will require future large-scale, multicenter randomized controlled trials; the present evidence does not establish that integrated teaching reliably produces each of these outcomes across institutions.

Subject of Research: Effects of postgraduate entrance examination preparation and integrated teaching on clinical internships among Chinese medical students

Article Title: The impact of postgraduate entrance examination on clinical internship of clinical medical students in China: a systematic review and meta-analysis

Article References: Ao, R., Wei, L., Jiawei, L., Yi, C., Xiangyu, Z., Qinpei, W., Jiaojiao, L., Yun, G., & Shiqiao, L. (2026). The impact of postgraduate entrance examination on clinical internship of clinical medical students in China: a systematic review and meta-analysis. BMC Medical Education. https://doi.org/10.1186/s12909-026-10368-7

Image Credits: AI Generated

DOI: 10.1186/s12909-026-10368-7

Keywords: medical education, clinical internship, postgraduate entrance examination, China, systematic review, meta-analysis, integrated teaching, case-based learning, clinical skills, student attendance, impact, postgraduate