Application of renal pathology three-dimensional animation in clinical clerkship teaching for medical students: a randomized-controlled trial

ERCT Criteria Breakdown

• Level 1 Criteria

  • C

    Class-level RCT

    • Randomization was at the individual student level rather than at the class (or higher) level.
    • "students were first randomly assigned using a random number table to either the conventional teaching group or the 3D animation group in a 1:1 ratio" (Page 4 of 7)
    • Relevant Quotes: 1) "93 students undertaking nephrology clerkships were randomly assigned 1:1 to either a conventional teaching group or a 3D animation group (intervention group)." (Page 2 of 7) 2) "students were first randomly assigned using a random number table to either the conventional teaching group or the 3D animation group in a 1:1 ratio (clinical trail registration number: ChiCTR2500112643, 2025-11−18, retrospective registration)." (Page 4 of 7) 3) "Within each program, both the traditional teaching group and the 3D animation group received instruction from the same instructor on the same day, with sessions held consecutively and separated by a few minutes." (Page 3 of 7) Detailed Analysis: Criterion C requires that treatment assignment occur at the class level (or stronger, e.g., site/school level) to reduce cross-group contamination when the intervention is delivered in a shared instructional environment. The paper repeatedly describes random assignment of "students" (individuals) to conditions. It does not describe intact classes, clerkship cohorts, or whole institutions being randomized. The teaching context also suggests the two conditions were delivered by the same instructor on the same day in consecutive sessions, which increases the plausibility of contamination or spillover at the individual level (e.g., students discussing the materials). The tutoring exception does not apply here because the intervention is an instructional medium used in group teaching activities rather than one-to-one tutoring. Final Summary: Criterion C is not met because randomization occurred at the individual student level rather than at the class (or higher) level.
  • E

    Exam-based Assessment

    • The outcome exams were locally developed (Test A/Test B) rather than a widely recognized standardized exam.
    • "Two examination sets (Test A and Test B) of comparable difficulty, developed by senior nephrology faculty and renal pathologists, were uniformly administered as pre- and post-intervention assessments" (Page 4 of 7)
    • Relevant Quotes: 1) "Teaching effectiveness was assessed via written examinations." (Page 4 of 7) 2) "Two examination sets (Test A and Test B) of comparable difficulty, developed by senior nephrology faculty and renal pathologists, were uniformly administered as pre- and post-intervention assessments to all participants across teaching groups and academic programs." (Page 4 of 7) 3) "Exam content, based on the syllabus and clinical diagnostic or therapeutic needs, covered renal pathology and related nephrology knowledge." (Page 4 of 7) Detailed Analysis: Criterion E requires exam-based assessment using a standardized, widely recognized instrument (e.g., national/state standardized exams or well-validated common instruments), rather than a test created for a specific study context. The paper explicitly states that the assessments (Test A and Test B) were "developed by senior nephrology faculty and renal pathologists" and based on the syllabus/clinical needs, indicating a locally constructed instrument. Although the paper notes steps intended to reduce alignment bias ("The exam developers were blinded to the specific content of the 3D animations."), this does not make the exams standardized in the ERCT sense. Final Summary: Criterion E is not met because the exams were locally developed for this study context rather than being standardized external exams.
  • T

    Term Duration

    • Outcomes were measured immediately after teaching within a 2-week rotation, not at least one academic term after intervention start.
    • "Both groups underwent a teaching effectiveness evaluation immediately following the session." (Page 4 of 7)
    • Relevant Quotes: 1) "During routine clinical teaching activities (e.g., mini- lectures, case discussions, teaching rounds), the renal pathology 3D animations were directly integrated into targeted explanations of relevant topics throughout the standardized 2-week clerkship rotation period." (Page 3 of 7) 2) "Both groups underwent a teaching effectiveness evaluation immediately following the session." (Page 4 of 7) Detailed Analysis: Criterion T requires that outcomes be measured at least one full academic term after the intervention begins (roughly 3-4 months), or at minimum that follow-up tracking extends to a term even if the intervention itself is shorter. The study states the teaching occurred in a "standardized 2-week clerkship rotation period" and that evaluation occurred "immediately following the session." This is far shorter than a term, and no term-delayed follow-up assessment is reported. Final Summary: Criterion T is not met because outcome measurement occurred immediately after teaching within a 2-week period rather than after at least one academic term.
  • D

    Documented Control Group

    • The control group condition and baseline comparability (including group sizes and baseline demographics/scores) are clearly reported.
    • "Conventional teaching group received instruction using traditional PowerPoint slides, including schematic diagrams and histopathological images, to explain renal microstructure and various pathological features." (Page 4 of 7)
    • Relevant Quotes: 1) "Conventional teaching group received instruction using traditional PowerPoint slides, including schematic diagrams and histopathological images, to explain renal microstructure and various pathological features." (Page 4 of 7) 2) "These students were allocated to the conventional teaching group (n=47), consisting of 28 clinical medicine and 19 stomatology students, and the 3D animation group (n=46), with 27 clinical medicine and 19 stomatology students." (Page 5 of 7) 3) "The group comprised 51 males and 42 females, with no significant difference in gender distribution between groups (59% male vs. 51% male, p=0.46). The mean age was slightly higher in the conventional teaching group (21.6 years vs. 20.4 years, p=0.04)." (Page 5 of 7) 4) "According to Table 1, pre-teaching assessment revealed comparable baseline performance between the two student groups (48.3±35.8 vs. 50.1±35.3, p=0.08)." (Page 5 of 7) Detailed Analysis: Criterion D requires a well-documented control group, including a clear description of what control participants received and enough baseline information to judge comparability. The paper specifies the control condition (traditional PowerPoint slides with diagrams and histopathological images). It also reports group sizes and program composition, baseline demographics (gender distribution, age), and baseline performance on the pre-teaching assessment. This is sufficient documentation to understand the control group and compare it to the intervention group. Final Summary: Criterion D is met because the control condition and baseline group characteristics/performance are clearly documented.

• Level 2 Criteria

  • S

    School-level RCT

    • The study randomized students, not schools or comparable institutional units, so it is not a school-level RCT.
    • "93 students undertaking nephrology clerkships were randomly assigned 1:1" (Page 2 of 7)
    • Relevant Quotes: 1) "93 students undertaking nephrology clerkships were randomly assigned 1:1 to either a conventional teaching group or a 3D animation group (intervention group)." (Page 2 of 7) 2) "students were first randomly assigned using a random number table to either the conventional teaching group or the 3D animation group in a 1:1 ratio" (Page 4 of 7) Detailed Analysis: Criterion S requires randomization at the school (or equivalent implementation unit/site) level. The paper describes assignment of individual students during clerkships within a single setting and does not describe multiple schools, hospitals, or sites being randomized. Final Summary: Criterion S is not met because the unit of randomization is the individual student rather than schools/sites.
  • I

    Independent Conduct

    • The authors developed the 3D animations and also performed core evaluation activities (including analysis), with no clear independent evaluator.
    • "Faculty members on the research team first referred to the syllabus and teaching objectives." (Page 3 of 7)
    • Relevant Quotes: 1) "Faculty members on the research team first referred to the syllabus and teaching objectives." (Page 3 of 7) 2) "The questionnaires were designed by the researchers based on a review of relevant literature." (Page 4 of 7) 3) "QZ and WJW analyzed the data." (Page 7 of 7) 4) "The realism and accuracy of the 3D animations were independently reviewed and validated by a multidisciplinary panel comprising the teaching director, teaching supervisors, course instructors, and renal pathology specialists." (Page 3 of 7) Detailed Analysis: Criterion I requires that the evaluation be conducted independently from those who designed the intervention, to reduce risks of bias in implementation, measurement, analysis, and reporting. The paper shows the research team developed the 3D animations and also designed questionnaires and analyzed the data. The only explicit "independent" activity described is an independent review of the animations' realism/accuracy, which is a content validation step and not an independent evaluation team for the trial outcomes. The article does not identify a third-party evaluator independent from the animation developers who ran the study and performed the outcome analysis. Final Summary: Criterion I is not met because the intervention developers also conducted key evaluation tasks without clearly independent evaluation conduct.
  • Y

    Year Duration

    • The intervention and outcome measurement occurred within a 2-week rotation with immediate post-testing, far shorter than 75% of an academic year; also, Y cannot be met if T is not met.
    • "throughout the standardized 2-week clerkship rotation period" (Page 3 of 7)
    • Relevant Quotes: 1) "During routine clinical teaching activities (e.g., mini- lectures, case discussions, teaching rounds), the renal pathology 3D animations were directly integrated into targeted explanations of relevant topics throughout the standardized 2-week clerkship rotation period." (Page 3 of 7) 2) "Both groups underwent a teaching effectiveness evaluation immediately following the session." (Page 4 of 7) Detailed Analysis: Criterion Y requires outcome measurement at least 75% of an academic year after the intervention begins. The paper clearly indicates the clerkship rotation was "standardized 2-week" and that evaluation occurred immediately after teaching. This is far shorter than a year-long tracking window. Additionally, per ERCT rules for this task, if criterion T is not met then criterion Y is not met. Since this study measures outcomes immediately (T not met), Y must be not met. Final Summary: Criterion Y is not met because the study duration and measurement timing are far shorter than an academic year and T is not met.
  • B

    Balanced Control Group

    • Teaching time/objectives were standardized across groups and the main difference was the instructional medium; any extra post-session access to animations is unlikely to affect the immediate outcome.
    • "This plan ensured that the core learning objectives and key knowledge points were identical across both instructional methods." (Page 3 of 7)
    • Relevant Quotes: 1) "Within each program, both the traditional teaching group and the 3D animation group received instruction from the same instructor on the same day, with sessions held consecutively and separated by a few minutes." (Page 3 of 7) 2) "This plan ensured that the core learning objectives and key knowledge points were identical across both instructional methods." (Page 3 of 7) 3) "Both groups underwent a teaching effectiveness evaluation immediately following the session." (Page 4 of 7) 4) "Students in the 3D animation group were subsequently provided with an online link to access the animations for self-directed review." (Page 4 of 7) 5) "All teaching materials including 3D animations and PowerPoint slides were distributed to all participants after the course completion." (Page 4 of 7) Detailed Analysis: Criterion B compares the nature, quantity, and quality of resources (time, budget, materials, adult support) across conditions, and asks whether the control condition provides a comparable substitute for the intervention’s inputs, unless differences in resources are explicitly the treatment variable. Here, both groups were taught by the same instructor on the same day with a standardized plan and identical core objectives/knowledge points. This indicates an intention to keep instructional time and teacher attention comparable while changing the instructional medium (slides vs. 3D animations), which is the intervention being tested. The 3D group had additional access to the animations via an online link for later self-directed review, which is an extra resource. However, the outcome assessment occurred "immediately following the session," so this post-session access is unlikely to have affected the measured exam results. Additionally, all materials were distributed to all participants after course completion, reducing longer-run resource imbalance. Final Summary: Criterion B is met because instructional time/objectives appear standardized across groups and any extra resources are unlikely to explain the immediate post-session outcome differences.

• Level 3 Criteria

  • R

    Reproduced

    • No independent, peer-reviewed replication of this specific RCT was identified.
    • "the participant pool was restricted to students undertaking clerkships at a single academic medical center" (Page 6 of 7)
    • Relevant Quotes: 1) "First, the participant pool was restricted to students undertaking clerkships at a single academic medical center, which may limit the generalizability of the results to other institutions or student populations with different educational backgrounds." (Page 6 of 7) 2) "Future studies involving multi-center collaborations, long-term assessments, and more objective evaluation metrics are warranted to validate and extend these findings." (Page 6 of 7) Detailed Analysis: Criterion R requires that the study be independently replicated by a different research team (and published in a peer-reviewed journal), reproducing the same core intervention/claim. The article presents a single-center study and explicitly frames the need for future multi-center and long-term work, which is consistent with replication not yet being established within the paper itself. An internet search was conducted to identify independent replications that explicitly reproduce this specific renal-pathology 3D animation clerkship RCT (same core intervention and design) by a different author team. No such independent replication paper was found. Final Summary: Criterion R is not met because independent reproduction of this specific RCT was not identified.
  • A

    All-subject Exams

    • The study did not use standardized exams (so E is not met), and it assessed only renal pathology/nephrology knowledge rather than all core subjects.
    • "Exam content, based on the syllabus and clinical diagnostic or therapeutic needs, covered renal pathology and related nephrology knowledge." (Page 4 of 7)
    • Relevant Quotes: 1) "Exam content, based on the syllabus and clinical diagnostic or therapeutic needs, covered renal pathology and related nephrology knowledge." (Page 4 of 7) Detailed Analysis: Criterion A requires standardized exam-based assessment across all main subjects, and (per the ERCT rules in this task) cannot be met if criterion E is not met. This paper’s outcome exam content is limited to renal pathology/nephrology knowledge, and the exams are locally developed rather than standardized. Final Summary: Criterion A is not met because E is not met and the assessments are limited to renal pathology rather than all core subjects.
  • G

    Graduation Tracking

    • The paper reports no long-term follow-up (including no tracking to graduation), and G cannot be met if Y is not met.
    • "The lack of long-term follow-up to evaluate knowledge retention and the enduring impact of the animations represents a significant limitation." (Page 6 of 7)
    • Relevant Quotes: 1) "Third, the assessment of teaching effectiveness and satisfaction relied on immediate post-intervention examinations and questionnaires." (Page 6 of 7) 2) "The lack of long-term follow-up to evaluate knowledge retention and the enduring impact of the animations represents a significant limitation." (Page 6 of 7) Detailed Analysis: Criterion G requires that participants be tracked until graduation for the relevant educational stage, potentially via follow-up publications by the same authors. The paper explicitly states that the evaluation relied on immediate post-intervention examinations/questionnaires and highlights the lack of long-term follow-up, which directly indicates that graduation tracking was not performed or at least not reported. In addition, per ERCT task rules, if criterion Y is not met then criterion G is not met. Since Y is not met in this study (2-week duration with immediate assessment), G must be not met. An internet search was conducted for follow-up publications by the same author team tracking the same cohort to longer-term outcomes (including graduation), but no such follow-up paper was identified. Final Summary: Criterion G is not met because the study reports no long-term follow-up to graduation and Y is not met.
  • P

    Pre-Registered

    • The trial was registered retrospectively on 2025-11-18 after the study period (August–October 2025), so it was not pre-registered.
    • "Trial registration Chinese Clinical Trial Registry ChiCTR2500112643, 2025-11-18, retrospective registration." (Page 2 of 7)
    • Relevant Quotes: 1) "Trial registration Chinese Clinical Trial Registry ChiCTR2500112643, 2025-11-18, retrospective registration." (Page 2 of 7) 2) "Undergraduate students completing clerkships in the nephrology department between August 2025 and October 2025 were enrolled." (Page 2 of 7) 3) "students were first randomly assigned using a random number table to either the conventional teaching group or the 3D animation group in a 1:1 ratio (clinical trail registration number: ChiCTR2500112643, 2025-11−18, retrospective registration)." (Page 4 of 7) Detailed Analysis: Criterion P requires that a full study protocol be registered publicly before the study begins (before enrollment/data collection). The paper explicitly labels the registration as "retrospective registration" and provides a registration date of 2025-11-18, while stating that clerkships/enrollment occurred between August 2025 and October 2025. This places registration after enrollment and likely after data collection. A web search was attempted to locate the public ChiCTR record for ChiCTR2500112643 to confirm dates directly in the registry; however, an accessible public registry entry with extractable verbatim text could not be located via available sources during this check. Because the paper itself explicitly states retrospective registration and dates, the criterion decision can still be made. Final Summary: Criterion P is not met because the registration is explicitly retrospective and dated after the study period began.