Peer-led examination simulation reshapes psychophysiological and emotional state profiles during problem-based medical learning

This is the authors' abstract. We don't add key points for this paper.

Problem-based learning is widely assumed to activate students through self-directed inquiry, collaborative reasoning, and contextualized problem solving, yet the psychophysiological and achievement-emotional state dynamics generated by regular PBL sessions remain poorly characterized. In particular, familiar PBL routines may not always provide sufficient salience, accountability, or retrieval-related activation to fully engage the learner states they are intended to promote. This repeated-measures study examined whether embedding a peer-led examination simulation into regular PBL reshapes students’ psychophysiological and achievement-emotional state profiles during medical learning. Forty-two medical students were assessed across resting baseline, regular PBL, and PBL with peer-led examination simulation. Heart rate variability was recorded during two 5-minute performance intervals per learning condition and analyzed using RMSSD, SDNN, pNN50, and LF/HF ratio. Psychological measures captured social interaction anxiety, perceived stress, state anxiety, achievement emotions, self-rated performance, and post-session appraisal. Both PBL formats reduced heart rate variability relative to baseline, indicating that regular PBL itself constituted an autonomically active learning state. Compared with regular PBL, peer-led examination simulation induced additional HRV withdrawal, reflected by lower RMSSD, SDNN, and pNN50, whereas LF/HF did not show a robust condition effect. Baseline-adjusted interval-level mixed models replicated the examination-simulation effect for RMSSD, SDNN, and pNN50. At the achievement-emotional level, the simulation increased anxiety and perceived stress while reducing boredom. Enjoyment, motivation, and self-rated performance remained stable. Students also reported greater perceived benefit from, and stronger preference for, the examination-simulation format. Exploratory analyses further indicated that stronger increases in anxiety were associated with stronger additional RMSSD withdrawal, suggesting convergence between achievement-emotional activation and autonomic regulation. These findings show that peer-led examination simulation does not merely add stress to PBL, but shifts the learning episode toward a more salient, assessment-like, and educationally valued psychophysiological state without compromising students’ motivation. More broadly, the study positions psychophysiological measurement as a tool for examining how instructional design modulates achievement-emotional dynamics, attentional engagement, and autonomic regulation during authentic medical learning.