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Problem based learning in continuing medical education: a review of controlled evaluation studies

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• Peer review
• P B A Smits , occupational physician ( p.b.smits{at}amc.uva.nl ) a ,
• J H A M Verbeek , PhD occupational physician b ,
• C D de Buisonjé , educational researcher a
• a Netherlands School of Occupational Health, PO Box 2557, 1000 CN Amsterdam, Netherlands,
• b Coronel Institute, Academic Medical Centre/University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, Netherlands
• Correspondence to: P B A Smits
• Accepted 20 September 2001

Problem based learning is one of the best described methods of interactive learning, and many claim it is more effective than traditional methods in terms of lifelong learning skills, and is more fun. 1 In the early 1990s, four systematic reviews of undergraduate medical education cautiously supported the short term and long term outcomes of problem based learning compared with traditional learning. 2 – 5 Since then, many medical curricula have changed to problem based learning, but a recent review has questioned the value of problem based learning in undergraduate medical education. 6

Postgraduate and continuing medical education differ from undergraduate education in that they go beyond increasing knowledge and skills to improving physician competence and performance in practice, ultimately leading to better patient health. 7 Problem based learning may also be effective in this context. 8 There is some evidence that interactive sessions can change professional practice, but there have been few well conducted trials. 9 10

We could find no reviews of the effectiveness of problem based learning in continuing medical education. Controlled evaluation studies provide the best evidence of effectiveness of educational methods, in line with the movement of best evidence medical education. 11 We therefore conducted a systematic review of the literature to find out if there is evidence that problem based learning in continuing medical education is effective.

Summary points

Reviews of undergraduate medical education cautiously support the short term and long term outcomes of problem based learning compared with traditional learning

The effectiveness of problem based learning in continuing medical education, however, has not been reviewed

This review of controlled evaluation studies found limited evidence that problem based learning in continuing medical education increased participants' knowledge and performance and patients' health

There was moderate evidence that doctors are more satisfied with problem based learning

Literature search

We searched the databases Medline, Embase, Psyclit, the Educational Resources Information Centre (ERIC), the Cochrane Library , and the Research and Development Resource Base in CME on the Internet (RDRBWEB) from 1974 (the year Neufeld and Barrows published their new approach to medical education) to August 2000. We searched for studies with the keywords “problem-based (PBL),” “practice-based,” “self-directed,” “learner centred,” and “active learning.” We combined the search results with another search using the keywords “continuing medical education (CME),” “continuing professional development (CPD),” “post-professional,” “postgraduate,” and “adult learning.” Finally, we conducted a manual search of relevant references in the included studies.

Inclusion criteria

We included studies in which the author(s) had indicated that the educational intervention was problem based and in which the learning process in essence resembled the methods used at McMaster University or the University of Maastricht. 12 13 This consists of a tutor facilitated, problem based learning session in which a small, self directed group starts with a brainstorming session. A problem is posed that challenges their knowledge and experience. Learning goals are formulated by consensus, and new information is learnt by self directed study. It ends with a group discussion and evaluation.

For this review, we included keywords to find relevant educational articles in the total domain of postgraduate and continuing medical education and continuing professional development. We scanned all the studies collected for controlled trials with a pretest/post-test design. Because of the small number of randomised trials, we did not exclude other types of controlled trial. With this strategy, we hoped to find all relevant controlled studies on problem based learning in continuing medical education.

Review method of selected studies

Two reviewers (PBAS and JHAMV) independently assessed the quality of the studies using five quality criteria. Each criterion was allotted a maximum of 10 points, making a maximum possible score of 50 points (see appendix on bmj.com for more details). We discarded a sixth possible criterion, that groups should be treated equally, with the exception of experimental education. 14 Many factors may influence the outcome of education (tutor, educational materials, lecture rooms, etc), and it was not possible to extract this information from the studies: we therefore could not assess equal treatment of groups.

Studies with a total score of ≥25 points were considered to be of high quality, and those with <25 points were of low quality. We distinguished two different categories of study by the control groups: in one category problem based learning was compared with a more lecture based programme, while in the other it was compared with no educational intervention.

Outcome variables

For each study, we looked for four outcome variables— participants' knowledge, performance, and satisfaction and patients' health—and assessed the level of evidence on these. We graded the evidence for the effectiveness of problem based learning as strong if there was a positive outcome in two high quality studies, as moderate if there was a positive outcome in one high quality and one low quality study, as limited if there was a positive outcome in one high quality study or one or more low quality study, and none if there was a contradictory outcome or no outcome.

Quality assessment of six studies evaluating effectiveness of problem based learning in continuing medical education

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Results of six studies evaluating effectiveness of problem based learning in continuing medical education

Results of literature search

Six controlled trials met our inclusion criteria. 15 – 20 A manual search of references from these studies did not yield any new trials that met our criteria. Five of the studies assessed the effect of continuing medical education on general practitioners. Four studies contained over 50 participants, 16 – 18 20 and two had fewer than 20. 15 19

Table 1 shows the results of our quality assessment of the six studies. Two studies were of “high” quality, 15 17 and the others were “low.” Two of the trials were randomised trials. 15 16 In Heale et al's study, however, the group of randomly allocated doctors was combined with a group who did not want to participate in the entire study. 16 Whether the randomisation is valid in terms of equality of groups is unclear.

Results of studies

Table 2 shows the results of the six studies. Outcome measurement was often restricted to only one variable. No study measured both the preferred outcome variables—participants' performance and patients' health. In one of the high quality studies—problem based learning via email versus use of internet resources—neither educational programme increased participants' knowledge, but group size was small. 15 The other high quality study—problem based versus lecture based learning—showed positive results for problem based learning in terms of participants' knowledge, clinical reasoning, and satisfaction. 17 It is unclear whether these effects can be attributed to the problem based learning format, however, because of differing periods of educational exposure.

Table 3 shows the level of evidence we found for the outcome variables. With the three studies that compared problem based learning with another educational format, we found no evidence that problem based learning affected participants' knowledge and performance and moderate evidence that it increased participants' satisfaction. None of the studies measured patients' health. The other three studies compared problem based learning with no educational intervention and were of low quality. They show limited evidence that problem based learning was effective in improving participants' knowledge and performance and patients' health (table 3 ). Differing degrees of satisfaction cannot be compared in this study design.

Level of evidence on outcome variables measured in six studies evaluating effectiveness of problem based learning in continuing medical education

Conclusions

We found few relevant studies, of varying quality. There is no consistent evidence that problem based learning in continuing medical education was superior to other educational strategies in increasing doctors' knowledge and performance but moderate evidence that it led to higher satisfaction. There is limited evidence that problem based learning increased doctors' knowledge and performance and patients' health more than no educational intervention at all.

However, the studies in which the control group received no educational intervention can give information only on the effects of receiving education, not of the specific educational method. With the studies that compared problem based learning with another method, in order to deduce that one educational intervention is more effective, the content, process, and influencing variables in both interventions must be clearly stated. The information on the educational interventions given in the three studies can be rated as completely absent, 16 poor, 15 and reasonable. 17

In studies not restricted to problem based learning, there is some evidence that interactive educational methods in continuing medical education are more effective in changing doctors' performance and patients' health. 9 The results of this literature study on problem based learning in continuing medical education seem to be comparable with those on problem based learning in undergraduate medical education. 2 – 4

Studying the effectiveness of education is complex, 21 22 but we should be able to perform studies of higher quality than those reviewed here, especially when comparing educational methods. As our review found, it is apparently not impossible to randomise participants to different educational methods. We have to do better in defining an educational method and controlling what actually happens in educational practice. We also have to clarify the aims of our education. Is our objective to increase knowledge, change attitudes, or improve health care? Outcome variables should correspond with our objectives, and preferably several different variables should be measured, including participants' performance and patients' health. 9 There seems to be agreement that a small significant effect found is evidence of effectiveness. 21 23 Evaluation is further complicated by professional and social context, as is shown in research on implementation of guidelines. 24 This calls for randomisation, because observational studies can easily be biased by these factors.

Acknowledgments

Contributors: PBAS coordinated the systematic review, formulated the study hypothesis, performed the searches, assessed the quality of studies, and wrote the article. JHAMV initiated the review, helped formulate the study hypothesis, supervised the systematic approach of the review, reported on the results, and helped write the article. CDdB helped formulate the study hypothesis, performed the searches, and made a first review and draft of the study results. PBAS and JHAMV are guarantors for this article.

Editorials by Prideaux and Goldbeck-Wood and Peile

Funding This study was supported by the Netherlands Organisation of Scientific Research (NWO) as part of the priority programme on fatigue and work and by the Netherlands School of Occupational Health.

Competing interests None declared.

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Problem-Based Learning

Problem-Based Learning (PBL) uses clinical cases to stimulate inquiry, critical thinking and knowledge application and integration related to biological, behavioral and social sciences. Through this active, collaborative, case-based learning process, students acquire a deeper understanding of the principles of medicine and, more importantly, acquire the skills necessary for lifelong learning.

The goal is for students to:

• Acquire, synthesize and apply basic science knowledge in a clinical context
• Engage in critical thinking and problem-solving
• Develop the ability to evaluate their own learning and collaborate with peers
• Effectively use information technology and identify the most appropriate resources for knowledge acquisition and hypothesis testing
• Contextualize and communicate their knowledge to others
• Ask for, provide and incorporate feedback in order to improve performance

Each PBL group has six to nine students and a faculty facilitator. Case information is disclosed progressively across two or more sessions for each case. This process mimics the manner in which a practicing physician obtains data from a patient. PBL allows students to develop hypotheses and identify learning issues as the additional pieces of information about a patient are disclosed to the student.

The students identify learning issues and information needs and assign learning tasks among the group. The students discuss their findings at the next session and review the case in light of their learning.  At the conclusion of a case, the students create a concept map synthesizing the knowledge garnered over the course of their discussions to demonstrate their understanding of how the elements of the case integrate with and relate to one another.

Faculty Development Modules

Faculty interested in learning more about PBL should review these online learning modules.

Welcome to PBL: A Guide for Tutors

This module is required for new tutors and optional for experienced tutors who are interested in a refresher course. It is intended to serve as an introduction to facilitating small-group sessions in the PBL course. This video will show you what a PBL session looks like and demonstrates some tutor behaviors. Open the module and use password fsmpbl for access.

PBL Tutor Feedback Module

All tutors (new and experienced) must go through this brief training module to help you provide students with feedback in the context of the PBL course. Open the module (Safari or Firefox recommended) and sign in when prompted with your NetID and password. Completing the module will count toward CME credit.

Kristin Van Genderen, MD

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Nahzinine Shakeri, MD

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Conceptualizing Problem-Based Learning: An Overview

Department of Community Medicine, Adesh Medical College and Hospital, Kurukshetra, Haryana, India

Rajiv Mahajan

1 Department of Pharmacology, Adesh Institute of Medical Sciences and Research, Bathinda, Punjab, India

Tejinder Singh

2 Department of Paediatrics and Medical Education, SGRD Institute of Medical Sciences and Research, Amritsar, Punjab, India

In an attempt to restructure the medical undergraduate curricula so as to equip medical graduates with essential competencies expected of an Indian Medical Graduate (IMG) and to keep pace with the changing dynamics of health in India, the National Medical Commission has introduced competency-based medical education in Graduate Medical Education Regulations-2019.[ 1 ] Competency in medical graduates can be developed through the acquisition of knowledge integrated with clinical and attitudinal skills necessary to provide high-quality, effective patient care. Competency development is also influenced by the way medical educators facilitate the growth of an integrated knowledge structure in place of rote memorization of facts or procedural practice.

In view of the above, new learning strategies are required to be adopted by medical faculty across the country. These strategies need to focus on being learner centric, multidisciplinary, system based, integrated, and problem based. The SPICES model of educational strategies is a key tool for structuring the undergraduate medical curriculum and its key elements include: student centered, problem based, integrated, community based, elective, and systematic or a planned approach.[ 2 ]

Problem-based learning (PBL) is an important aspect of this new model and a contributor in competency-based learning method. PBL was introduced by McMaster University, Canada, in 1969 as a unique, hands-on approach to learning medicine.[ 3 ] It is pertinent to mention here that PBL is not the same as “problem-solving,” as the goal of learning is not to solve the problem which has been presented. Instead, the problem is used to help students identify their own learning needs as they attempt to understand the problem, to pull together, synthesize and apply information to the problem, and to work effectively to learn from group members as well as facilitators.[ 4 ]

The PBL approach, an innovative teaching and learning method, stands to provide greater challenges and motivation by making use of realistic scenarios to engage and interact with students by building on their prior knowledge, enhancing comprehension of basic concepts, and molding knowledge gained in silos to establish a complex yet elaborate and well-integrated knowledge structure. The knowledge structure so created aids in learning, as it integrates and concretizes theoretical knowledge with its clinical relevance. Furthermore, thoughtfully created problems can foster active and deep learning (as students interact with learning materials and relate concepts to everyday activities), improve understanding, knowledge retention, and development of lifelong learning skills. PBL also allows students to activate prior knowledge and build on existing conceptual knowledge frameworks and thereby develop generic skills and attitudes such as teamwork, communication, respect for colleagues, critical evaluation, self-directed learning and use of resources, cooperation, and presentation skills desirable for their future practice [ Figure 1 ], PBL is interesting for students and tutors as the process requires all students to be engaged in the learning process.[ 5 ]

Prerequisites and outcomes of problem-based learning. PBL: Problem-based learning, SCC: Structuring in clinical context, CRP: Clinical reasoning process, MOL: Motivation of learning

In PBL, the student controls the reins for steering the learning process. It is a self-reflective process, and students learn to monitor their own learning. In PBL, students use “triggers” from the problem case or case scenario/vignette to identify and define their own learning objectives. This is followed by the independent, self-directed study before returning to the group to share, discuss, and refine their acquired knowledge. Thus, PBL uses problems as a base to increase knowledge and understanding. It would thus make sense to think of PBL as a small-group teaching technique that combines the acquisition of knowledge with the development of generic skills and attitudes. Clinical triggers serve as the stimulus for learning and enable students to understand the relevance of underlying scientific knowledge and its application in clinical practice.[ 6 ]

Commonly used trigger material for PBL scenarios includes paper-based clinical scenarios, laboratory reports, photographs, audio-video clips, newspaper articles, research publications, a real or simulated patient, and a family tree showing an inherited disorder.[ 6 ]

A typical PBL tutorial consists of a group of students (usually 8–10) and a facilitator/tutor to guide the session. The number and length of sessions should allow for effective group dynamics to develop. The tutor facilitates the process and ensures that the student group achieves appropriate learning objectives as conceptualized by the PBL curriculum design team. The tutor should encourage students to check their comprehension of the triggers/case material. This can be done by encouraging the students to engage in open conversation with the tutor and with other members in the group. “Seven jump” process is the most suited method for conducting PBL sessions.[ 6 ] PBL discussions differ from other small groups by the fact that the tutor has to push the students to the edge of their knowledge, setting the scene for further relevant learning.

The pillars of problem-based learning include small-group learning (tutorial-style setting and includes 8–10 student participants), faculty facilitation (to strike a balance between directing the tutorial and actively soliciting student feedback to ensure that a student's knowledge gap is adequately and appropriately addressed), use of patient-based cases (realistic clinical cases), and well-defined learning objectives (essential to ensure that students address the correct content and identify their strengths and weaknesses).

For the purpose of assessment, it is advisable to use an appropriate range of assessment methods following the basic principles of assessing the student in relation to the curriculum outcomes. It is also desirable to consider the assessment of the group in the form of reflections on its PBL performance, adherence to the process, communication skills, teamwork, respect for others, and individual contributions as these encourage students to achieve the generic attributes associated with PBL. Ample opportunities for process assessment must be there, along with content assessment.[ 7 ]

PBL is primarily based on the principles of adult learning, motivating, and encouraging the students to set learning goals, and allowing them to take decisions that affect their own learning. PBL also generates a more stimulating and challenging educational environment that has the potential to influence permanent change in behavior. PBL can be used as an intervention to promote self-directed learning and ultimately lifelong learning goal of IMG. Everyone may not be able to use the classical version, and partial implementation (with partial benefits) is possible. The benefits go far beyond simple pretest and posttest.

What, how and why is problem-based learning in medical education?

Problem-based learning, or PBL, is a pedagogical practice employed in many medical schools. While there are numerous variants of the technique, the approach includes the presentation of an applied problem to a small group of students who engage in discussion over several sessions. A facilitator, sometimes called a tutor, provides supportive guidance for the students. The discussions of the problem are structured to enable students to create conceptual models to explain the problem presented in the case. As the students discover the limits of their knowledge, they identify learning issues – essentially questions they cannot answer from their fund of knowledge. Between meetings of the group, learners research their learning issues and share results at the next meeting of the group.

How do faculty members participate in this process?

Why are medical schools incorporating pbl, can you give me an example of how the process works, what student skills should we encourage for pbl-focused medical education, enjoy reading asbmb today.

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Jose Barral is the associate dean for academic affairs at the UTMB Graduate School of Biomedical Sciences.

Era Buck is a senior medical educator in the Office of Educational Development and an assistant professor in the department of family medicine at the University of Texas Medical Branch in Galveston, Texas.

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• Corpus ID: 70607722

Problem-based learning : an approach to medical education

• H. Barrows , R. Tamblyn
• Published 1980
• Medicine, Education

1,585 Citations

Problem-based learning in medicine: an introduction., problem-based learning in medical schools: a new approach., the emergence of problem-based learning in medical education., problem-based learning and the medical school: another case of the emperor's new clothes, problem-based, self-directed learning., the impact of problem based learning versus conventional education on students in the aspect of clinical reasoning and problem solving.

• Highly Influenced

Problem Based Learning as a Curricular Strategy for Medical Undergraduates: A Tutor's Experience

Problem-based learning in the clinical laboratory science curriculum, early introduction to medical problem-solving., problem solving in undergraduate medical students, related papers.

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• Open access
• Published: 30 May 2024

Enhancing AI competence in health management: students’ experiences with ChatGPT as a learning Tool

• Lior Naamati-Schneider 1  

BMC Medical Education volume  24 , Article number:  598 ( 2024 ) Cite this article

362 Accesses

Metrics details

The healthcare industry has had to adapt to significant shifts caused by technological advancements, demographic changes, economic pressures, and political dynamics. These factors are reshaping the complex ecosystem in which healthcare organizations operate and have forced them to modify their operations in response to the rapidly evolving landscape. The increase in automation and the growing importance of digital and virtual environments are the key drivers necessitating this change. In the healthcare sector in particular, processes of change, including the incorporation of artificial intelligent language models like ChatGPT into daily life, necessitate a reevaluation of digital literacy skills.

This study proposes a novel pedagogical framework that integrates problem-based learning with the use of ChatGPT for undergraduate healthcare management students, while qualitatively exploring the students’ experiences with this technology through a thematic analysis of the reflective journals of 65 students.

Through the data analysis, the researcher identified five main categories: (1) Use of Literacy Skills; (2) User Experiences with ChatGPT; (3) ChatGPT Information Credibility; (4) Challenges and Barriers when Working with ChatGPT; (5) Mastering ChatGPT-Prompting Competencies . The findings show that incorporating digital tools, and particularly ChatGPT, in medical education has a positive impact on students’ digital literacy and on AI Literacy skills.

Conclusions

The results underscore the evolving nature of these skills in an AI-integrated educational environment and offer valuable insights into students’ perceptions and experiences. The study contributes to the broader discourse about the need for updated AI literacy skills in medical education from the early stages of education.

Peer Review reports

Introduction

In recent years, the healthcare sector has undergone significant shifts in both local and global contexts. These shifts are primarily attributed to demographic, technological, economic, and political factors. These changes have had a profound impact on the healthcare ecosystem, requiring organizations to adapt their operations and strategies to this evolving landscape [ 1 , 2 ]. In response, healthcare organizations have had to modify their behavior to adapt to this ever-changing reality [ 3 ]. Among the factors that have most significantly affected the healthcare system are technological advancements, automation, and the rise of digital and virtual environments. The impact of these factors gained momentum in December 2019, primarily due to the COVID-19 pandemic. Technological advances, particularly the rise of artificial intelligence (AI) and digital tools, have been central to this transformation, with the COVID-19 pandemic accelerating the need for healthcare systems to adapt and innovate [ 3 , 4 , 5 , 6 , 7 , 8 ]. The integration of AI in healthcare, including the deployment of chatbots like ChatGPT that utilize the Generative Pre-trained Transformer (GPT)—a type of large language model (LLM)—underscores a shift toward digital and AI literacy in medical education and practice. [ 9 , 10 ].

The adoption of AI in healthcare, highlighted by the use of systems like ChatGPT, marks a pivotal shift towards greater digital and AI literacy in medical education and practice [ 9 , 10 , 11 , 12 ]. This reflects the healthcare sector’s broader move towards technological innovation, aiming to enhance patient care and revolutionize healthcare professional training. Incorporating AI, such as ChatGPT, into educational frameworks prepares students for the complexities of modern healthcare, demonstrating AI’s potential to transform both healthcare delivery and professional skill development [ 11 , 12 ].

In the rapidly evolving landscape of AI, where technological developments are occurring at an accelerated pace, there is a significant need for comprehensive research to navigate this ever-changing landscape. In particular, research into the impact of AI on healthcare is still limited, highlighting the urgent need for more focused studies on the implications for medical education and the effective training of healthcare professionals in the use of AI technologies [ 13 , 14 ]. The emergence of LLMs, such as GPT, and their applications in educational frameworks, including chatbots like ChatGPT, has increased the urgency of reassessing the skills required, with a particular focus on digital literacy. This reassessment is essential to determine the continued relevance of these skills or whether a fundamental refocusing is required. Such a re-examination is essential to ensure that the healthcare workforce is adequately prepared for the challenges and opportunities presented by the integration of AI into healthcare practice [ 11 ].

Studies [ 15 , 16 , 17 , 18 ] have identified a significant gap in understanding how digital literacy skills—such as accessing, analyzing, evaluating, and creating digital content—play a role in effectively leveraging LLMs like GPT and their applications, including chatbots such as ChatGPT, within educational frameworks. Furthermore, the successful integration of ChatGPT into educational settings may potentially lessen the reliance on traditional digital literacy skills, prompting a reevaluation of their ongoing relevance [ 19 , 20 ]. This gap underscores the need for more research into the critical role that digital literacy skills hold in the efficient use of technologies like ChatGPT for educational aims, as highlighted by recent literature [ 15 , 17 , 18 ]. ChatGPT’s access to accurate medical information could reduce the need for individual data analysis skills [ 21 , 22 ]. Yet, concerns persist among researchers that its content generation might hinder critical thinking development, including source evaluation and idea generation [ 23 , 24 ].

This qualitative study introduces a pedagogical framework that synergizes problem-based learning with the application of ChatGPT among undergraduate healthcare management students. It aims to qualitatively examine their interactions with this technology, focusing on the transition from traditional digital literacy towards a more advanced AI literacy. This evolution in educational focus is poised to revolutionize the requisite competencies for navigating the dynamic healthcare sector of today.

The rationale behind focusing on ChatGPT stems from its notable accessibility, user-friendly design, and versatility as a comprehensive tool in healthcare settings. Its capability to simulate human-like dialogues positions it as a prime resource for educational initiatives, thereby enriching the pedagogical domain of healthcare management and clinical practices. The unrestricted access to ChatGPT, along with its wide-ranging utility in executing diverse healthcare operations, underscores its capacity to significantly contribute to and spearhead innovation within healthcare education and practices. The selection of ChatGPT, attributed to its approachability and adaptability, marks a strategic endeavor to investigate the impact of artificial intelligence amidst the shifting paradigms of healthcare requirements. Yet, despite the widespread integration of ChatGPT in healthcare, research into the long-term effects and the necessary adaptation of skills and methods remains lacking. [ 11 , 12 ].

Literature review

Ai tools in medical settings.

AI involves creating systems that mimic human cognitive functions such as perception, speech recognition, and decision-making through machine learning. It excels in analyzing data, identifying patterns, and making predictions, offering improvements over traditional data processing. AI’s applications span multiple sectors, including healthcare, at various levels from individual to global [ 25 , 26 ]. The integration of AI into healthcare enhances diagnostic, treatment, and patient care, offering advanced decision-making and predictions [ 9 , 10 , 25 , 27 ].AI technologies enhance clinical decision-making, diagnosis, and treatment by analyzing patient data through machine learning for informed decisions, offering 24/7 support via AI chatbots, and enabling remote monitoring with AI-powered devices like wearable sensors [ 9 , 28 ].

AI facilitates remote patient monitoring, minimizing in-person healthcare visits [ 29 ]. It improves service personalization, with AI assistants managing appointments and reminders, and chatbots streamlining insurance claims, easing provider workloads [ 9 ]. AI automates routine administrative tasks, freeing providers to concentrate on patient care. It streamlines operations, cuts bureaucracy, and analyzes data to improve healthcare management and predict service demand, allowing for better resource allocation. AI’s analysis of patient feedback further aids in enhancing service delivery [ 10 ]. AI integration can transform patient-caregiver dynamics, enhancing diagnosis, treatment, and self-management of health conditions [ 30 ]. While AI integration in healthcare promises significant advancements, it presents challenges, including data management issues and the need for specialized skills.

Sallam [ 14 ] highlights ChatGPT’s potential advantages in healthcare, including enhancing clinical workflows, diagnostics, and personalized medicine. However, challenges such as ethical dilemmas, interpretability issues, and content accuracy must be tackled. In healthcare education, although ChatGPT holds promise for customized learning and creating lifelike clinical scenarios, concerns about bias, plagiarism, and content quality persist. Addressing these concerns necessitates preparing healthcare professionals and students through education and training to navigate the complexities of AI. Additionally, extensive research in these domains is essential [ 6 , 9 , 14 , 31 , 32 ].

Teaching with AI and about AI: advancing education in the digital age

To be able to utilize AI tools effectively and integrate them seamlessly into their everyday work, healthcare professionals need early exposure to AI tools in their education to boost their proficiency and confidence, understanding both their potential and limitations [ 9 , 32 , 33 ]. York et al. [ 32 ] explored medical professionals’ attitudes towards AI in radiology, revealing a positive outlook on AI’s healthcare benefits but also highlighting a notable gap in AI knowledge. This emphasizes the need for enhanced AI training in medical education.

According to Sallam [ 14 ], ChatGPT and other models based on lLLMs have significantly improved healthcare education. They customize responses to student inquiries, curate relevant educational material, and tailor content to individual learning styles. For instance, ChatGPT generates personalized quiz questions, suggests resources to fill knowledge gaps, and adjusts explanations to suit diverse learning preferences. Moreover, it simplifies complex medical concepts, employs analogies and examples for clarity, and offers supplementary materials to enhance comprehension.

Breeding et al. [ 11 ] argued that in medical education, ChatGPT should be viewed as a supplementary tool rather than a substitute for traditional sources. While it offers clear and organized information, medical students still perceive evidence-based sources as more comprehensive. Eysenbach [ 33 ] engaged in a series of dialogues with ChatGPT to explore its integration into medical education. ChatGPT demonstrated proficiency in various tasks, such as grading essays, providing feedback, creating virtual patient scenarios, enhancing medical textbooks, summarizing research articles, and explaining key findings. Nevertheless, it also demonstrated a tendency to produce erroneous responses and fabricated data, including references. Such inaccuracies have the potential to generate student misconceptions, spread misinformation, and cause a decline in critical thinking skills [ 33 ]. Han et al. [ 34 ] conducted a comprehensive examination of ChatGPT’s effectiveness as a pedagogical tool in medical education, focusing on the chatbot’s interaction with delineated educational objectives and tasks. Their findings suggest that while ChatGPT is capable of providing elementary data and explanations, it is not impervious to constraints and sometimes provides incorrect or partial information. The study stresses active learning and analytical reasoning in medical education, emphasizing the importance of understanding basic sciences and the need for expert oversight to ensure AI-generated information accuracy [ 34 ].

Das et al. [ 35 ] evaluated ChatGPT’s efficacy in medical education, focusing on microbiology questions at different difficulty levels. They found that ChatGPT could answer basic and complex microbiology queries with roughly 80% accuracy, indicating its potential as an automated educational tool in medicine. The study underscores the importance of ongoing improvements in training language models to enhance their effectiveness for academic use [ 35 , 36 ].AI implementation in healthcare must be carefully managed to maximize benefits and minimize risks [ 11 , 12 , 35 , 36 ]. With the rapid development of digital technologies and AI tools, particularly in healthcare, students need appropriate resources to use these technologies effectively [ 37 ]. Digital literacy is essential in the 21st century, including skills for interacting with digital content [ 16 , 18 ]. Hence, medical literacy skills should start early in the education of healthcare students.

Digital literacy and eHealth literacy skills

Digital literacy skills encompass a collection of essential abilities necessary for using digital technologies effectively in accessing and retrieving information [ 38 ]. These skills are often viewed as foundational digital literacies that are critical for full participation in the digital era [ 39 ]. The European Commission emphasizes the importance of digital literacy for employability and citizenship. They advocate for policies and programs to enhance digital skills across all segments of society. The EU aims for 70% of adults to have basic digital skills by 2025, focusing on analytical, evaluative, and critical thinking abilities crucial for assessing digital information’s quality and credibility [ 40 ]. Individuals need these skills to discern biases and misinformation in various media formats [ 16 , 17 , 41 ] and evaluate the credibility of online sources [ 42 ]. Critical thinking is crucial for distinguishing between accurate information and misinformation [ 43 ], while data literacy is essential for interpreting data and detecting misleading statistics [ 44 ]. These competencies are fundamental for navigating today’s complex digital information landscape.

eHealth literacy, which incorporates the digital skills needed to access and utilize medical information from digital platforms [ 45 ], is gaining recognition as an integral component of overall health literacy. Enhanced online medical literacy is vital for healthcare professionals and administrators [ 46 ] to adapt to changing demands and improve care management within evolving healthcare paradigms [ 47 ]. Additionally, acquisition of digital competencies has been identified as a valuable strategy that healthcare providers and managers can use to manage the psychological effects of heightened workloads and uncertainty, such as the fear, stress, and anxiety emerging from the COVID-19 pandemic [ 48 ]. These skills enable individuals to use AI as both an independent tool and a supplementary aid in decision-making. However, addressing challenges like bias and academic integrity is crucial when integrating AI into medical education [ 32 , 33 , 49 ]. Critical thinking skills are essential for analyzing digital information, identifying inconsistencies, and evaluating arguments. In today’s era of misinformation, users must verify the accuracy of online content and distinguish between reliable sources and hoaxes [ 43 ]. Data literacy skills are also crucial for interpreting data accurately, detecting misleading statistics, and making informed decisions based on credible sources in the digital age [ 44 ].

Research on digital literacy emphasizes the importance of analytical and evaluative skills. Morgan et al. [ 17 ] found that higher education students struggle most with evaluating digital content for bias and quality. They excel in social literacy skills like communication. This highlights the need to prioritize adaptability in digital literacy, integrating industry-relevant experiences into education to ensure students can navigate and critically assess digital information for real-world applications.

Indeed, since the introduction of ChatGPT in 2022, it has been beneficial in various educational contexts. Nevertheless, concerns have been raised about potential inaccuracies and misinformation that may affect student learning and critical thinking [ 20 ]. Moreover, the potential redundancy of certain digital skills as a result of ChatGPT’s capabilities has also sparked discussions on changing educational objectives [ 19 , 21 , 22 ]. The development of ChatGPT may replace some digital skills as it takes over tasks previously expected of students. Researchers [ 21 , 22 ] argue that it is constantly improving its ability to access accurate medical information, providing reliable advice and treatment options from reputable sources. This ability may render the need for individuals to be adept at information retrieval and evaluation redundant. In other words, ChatGPT’s growing proficiency in tasks such as translation, text summarization, and sentiment analysis, and its ability to generate content like movies [ 23 ] may potentially lead to the underdevelopment of critical thinking skills, including the ability to evaluate source quality and reliability, formulate informed judgments, and generate creative and original ideas [ 24 ]. Indeed, the integration of AI into the healthcare sector raises critical questions about the nature and scope of the digital skills required in the future [ 19 , 20 ].

As AI advances, essential digital competencies may need reassessment to keep pace with technology. This requires forward-thinking digital literacy initiatives, particularly in healthcare education and practice. Proactively addressing the potential impact of AI on human interactions with digital healthcare technologies is critical. This will ensure that healthcare professionals and students are skilled in current digital practices, and prepared for the evolving role of AI in the sector. Despite the swift integration of AI tools in healthcare, and applications like ChatGPT, research on their long-term impacts, effects on users, and the necessary adaptation of skills and methodologies in the ever-evolving learning environment remains insufficient [ 11 , 12 , 15 , 17 , 18 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 ].

This study aims to address the intersection of AI adoption in healthcare and its implications for medical education, specifically focusing on the skills required by healthcare professionals. With the rapid incorporation of AI, into healthcare settings, there is an urgent need to reassess the digital literacy skills traditionally emphasized in medical education. This reassessment prompts questions about the ongoing relevance of these skills as AI technologies continue to evolve and expand their role in healthcare [ 13 , 15 , 16 , 17 , 18 , 19 , 20 ].

Research questions

Given the context, this study aims to explore the following qualitative research questions:

How does a pedagogical framework integrating problem-based learning with ChatGPT affect healthcare management undergraduates’ digital literacy skills?

What are students’ experiences with the combined use of problem-based learning and ChatGPT in their healthcare management education?

How do students perceive the shift towards AI-relevant skills as a result of engaging with this integrated pedagogical approach?

Methodology

Methodological approach.

The present research adopts the case study methodology, which entails in-depth empirical research of a current phenomenon within its real-world context [ 50 ]. This approach involves collecting data on human activities within a defined time and space setting, thereby facilitating an understanding of the various processes occurring within the research case. In qualitative research, and particularly in case study research, themes are formulated from the participants’ narratives, thus allowing for the development of arguments or generalizations derived deductively from participants’ statements [ 51 ]. By focusing on our research questions and using a methodological framework that emphasizes depth and context, the study aims to shed light on the transformative impact of AI on medical education and the development of the skills required for future healthcare professionals.

The research was conducted and analyzed by the researcher, who has a PhD in Healthcare Management and over 15 years of experience in qualitative analysis. Her expertise ensures a deep understanding of the study’s qualitative data. Throughout the research, she engaged in continuous reflexive practices to evaluate how her subjectivity and context influenced the study. This included reflecting on her assumptions, considering power dynamics with participants, aligning research paradigms and methods, and understanding the research context [ 59 ].

Participants and research population

The study involved 89 third-year undergraduate students enrolled in a Health System Management degree program, specifically participating in a course on Service Quality in the Healthcare System during the 2023 academic year. The researcher, serving as the lecturer for this course, integrated writing reflective journals into the curriculum as part of the learning process. Following the course’s conclusion and after grades were distributed, the researcher asked students, in adherence to ethical guidelines, if they consented to have their reflective journals analyzed for research purposes, as outlined in the data collection section. Only students who completed all components of the intervention plan outlined for the class were considered potential participants in the research population.

From this group, qualitative data was extracted from the reflective journals of 65 students who consented to participate. The demographic breakdown of this participant subset included 80% females, with an average age of 24.26 years (Standard Deviation = 3.80).

Data collection

Throughout the course, participants were required to keep a reflective journal documenting their learning journey, to be submitted at the end of the semester. The aim of writing the journal was to capture their personal perceptions of their learning experience. They were encouraged to articulate various challenges, obstacles, and positive and negative aspects they encountered [ 52 ]. Specifically, they were asked to describe the main challenges they faced and the obstacles they overcame, and to provide an introspective account of their experiences. The practice of writing a personal journal not only served as a tool for reflection but also helped them adopt a comprehensive perspective on their educational process [ 53 ].

The credibility of the reflective journal prompts was assured by grounding their development in an extensive literature review and expert consultations within the field of healthcare education. This process ensured that the prompts accurately reflected the constructs of interest, facilitating consistent and meaningful student reflections. Content validity was emphasized to ensure the journal prompts were aligned with the study’s objectives and relevant to students’ experiences in healthcare management education. Refinement of these prompts to effectively meet research objectives was facilitated through expert input. A detailed coding scheme was developed, featuring definitions and categories reflecting the study’s aims and insights from the journals. The coding was applied to a subset of journals by the researcher to ensure credibility.

The data were collected from the reflective journals in accordance with the intervention plan outlined in the Instructional Method section. The study carefully complied with several ethical guidelines for research with human subjects. The nature and purpose of the research were fully explained to the students, with particular emphasis on the use of reflective journals to evaluate the intervention plan. The students gave their informed consent and signed consent forms. To ensure confidentiality, participants were informed that all names would be replaced by pseudonyms and all identifying details would be removed from the final research report. They were also explicitly told that the journal entries would be processed anonymously. The research was approved by the college’s Ethics Committee.

Instructional method procedure (intervention plan)

The focus of this study is a required course titled Introducing Quality into the Health System, which had formerly been taught using traditional frontal teaching methods. The study examines the transformation of this course into a course taught using ChatGPT-mediated online guided learning. This innovative learning approach provides learners a comprehensive experience that entails self-directed learning. The approach emphasizes problem-based learning and focuses on identifying ethical dilemmas and analyzing them within organizational contexts. The intervention plan was strategically organized into five primary stages. Each stage comprised a series of carefully constructed steps that were specifically designed to build upon the knowledge and skills acquired in the previous stages, thus ensuring a coherent and cumulative educational progression. Figure  1 summarizes the instructional method.

Initial Familiarization with ChatGPT

At the beginning of the course, students were introduced to ChatGPT to develop their understanding and proficiency with the tool. This involved providing them detailed instructions on effective usage and encouraging them to engage in interactive dialogues with ChatGPT. The aim was to foster a sense of familiarity and ease, thereby facilitating an informal, hands-on learning experience.

Exploratory Analysis of a Dilemma using ChatGPT

In this exploratory stage, students began to examine the topic of hospital accreditation. Through interactions with ChatGPT, they were introduced to the pros and cons of the accreditation process and to the dilemmas posed by following the accreditation guidelines. The issue of accreditation is central to the discourse on how to improve healthcare quality, but it is also fraught with challenges, such as staff shortages and funding issues. Hospitals have had to make significant changes to meet accreditation standards, leading to debates about possible abolition of the accreditation system. While accreditation is crucial for quality control, its associated costs, particularly those related to inspections and the need for additional staff, pose significant challenges. Without proportional funding, compulsory accreditation has placed financial pressures on hospitals, creating a complex dynamic for both the Ministry of Health and healthcare institutions as they navigate the accreditation process.

To explore the topic of accreditation in depth, students were instructed to develop a series of questions to input to ChatGPT aimed at extracting detailed information about the accreditation dilemma. Students engaged with ChatGPT by posing questions and critically analyzing the answers from three perspectives: organizational, healthcare worker, and patient/customer. They iteratively refined their queries to increase precision until they achieved a comprehensive understanding. Following guidelines, they condensed and reorganized the information into a structured paragraph, incorporating the core dilemmas and arguments from each perspective. To meet objectives, students demonstrated digital media skills, including locating and sharing relevant materials, analyzing ChatGPT responses, verifying sources, and assessing content credibility.

Synthesis and Documentation of Concepts Emerging through ChatGPT Interaction

In the third stage, students were required to submit a comprehensive list detailing new concepts, themes, and sub-themes that emerged from their learning experience with ChatGPT. Their submitted list was not limited to the final results, but also included documentation of all stages of their work, including their initial set of questions, their subsequent refinement of these questions, and the process of their development throughout the learning journey. In addition, they were required to provide a final section summarizing the culmination of their exploration and learning process with ChatGPT. This comprehensive approach was designed to demonstrate the students’ engagement and progression with the tool and to highlight their ability to develop their inquiries and synthesize information effectively.

Analytical Structuring of Learning Outcomes

In the fourth stage, students attempted to refine the learning outcomes they had previously generated. Following the established guidelines, their main objective was to identify and highlight the pros and cons of the various arguments related to the dilemmas they had studied, making sure to consider them from different perspectives. The challenge was to present their arguments in a coherent and logical order, for example by comparing budgetary considerations with quality considerations. They were also expected to support each argument with scientific evidence, thereby aligning their analysis with academic accuracy and empirical research. This stage was crucial in developing their ability to critically evaluate and articulate complex issues, particularly in the field of healthcare.

Final project: Integrative Analysis and multidimensional presentation

In the final stage, students developed and presented a final project, building upon their prior work to explore a comprehensive research question or delve into a specific aspect of their study. This included presenting organizational and managerial viewpoints. The choice of format and tools for their project and presentation—ranging from e-posters and slides to video clips, using familiar technologies like PowerPoint and ThingLink—was left to the students. This method fostered diversity and empowered students by allowing them to select their preferred presentation technique. Moreover, the project featured a peer review phase where students critiqued each other’s work through insightful questions and suggestions, enhancing the discussion. This interactive element aimed to bolster critical thinking and collaborative learning.

Summary of instructional method

Reflective Journaling: documenting the Learning Journey

Throughout the semester, students kept a reflective journal, which they submitted at the end of the course. The primary aim of this journal was to document their personal learning experiences. The journal provided a window on their challenges, difficulties and successes they encountered, all viewed through the lens of their own perceptions and experiences.

Data analysis

The present research employed a deductive-inductive method for categorical analysis of the dataset. Integration of these deductive and inductive approaches was essential to facilitate investigation of predefined categories that are grounded in extant literature and theoretical frameworks, as well as to permit the discovery of novel categories that surfaced during the analysis process [ 51 ]. Initially, the deductive stage was conducted, focusing on predefined categories derived from existing literature and theoretical frameworks. Following this, the inductive stage allowed for the identification and development of novel categories based on the data analysis. The inclusion of episodes, thoughts, and feelings expressed by the students in this study serves to reinforce the reliability of the identified themes. The analysis of the reflective journals began with in-depth reading to identify initial themes from students’ narratives. Inductive coding facilitated the identification and development of themes by the researcher, rather than merely allowing them to ‘emerge.’ This active interpretation and organization of the data by the researcher led to a compilation of key insights. After ensuring the reliability and validity of these findings through careful review, the researcher then organized the codes into themes and sub-themes, ensuring they accurately reflected the data and provided a clear narrative of the students’ experiences.

The findings

The researcher’s analysis of the reflective journals actively uncovered five main categories: (1) Use of Literacy Skills; (2) User Experiences with ChatGPT; (3) ChatGPT Information Credibility; (4) Challenges and Barriers when Working with ChatGPT; (5) Mastering ChatGPT Prompting Competencies. Table  1 summarizes the identified categories and subcategories. To further clarify each category, the table includes representative quotations from the data for illustrative purposes. Throughout the manuscript, pseudonyms have been used with quotations. This approach ensures confidentiality and anonymity for all participants.

Use of literacy skills

The category comprising the use of literacy skills, the code refers to instances where participants relate literacy skills such as reading comprehension, searching evaluation of Information, etc., in their interactions with ChatGPT.

It includes three subcategories: Search Strategies and Access to Data in ChatGPT Use; Data Analysis Enhancement with ChatGPT ; and Evaluation of Information in ChatGPT Interactions Search Strategies and Access to Data in ChatGPT Use.

In the reflective journals, the students consistently expressed their high regard for the efficiency and ease of searching for and accessing information through ChatGPT. The chat interface significantly improved the process of retrieving information by removing the necessity to navigate through multiple websites or sources, thereby making the material more accessible. Furthermore, the interface’s user-friendly and accessible content format played a crucial role in significantly enhancing students’ understanding of the material. Shir wrote: The chat was super easy and helpful in making the dilemma clearer for me. It put all the info I needed in one spot, and everything was explained in a way that was simple to understand.

The analysis of the student journals underscored the remarkable proficiency of ChatGPT in rapidly and effortlessly providing information for various tasks. This technology alleviated the necessity for students to delve into multiple sources, offering a direct approach for understanding concepts, interpreting implications, and compiling data for complex issues. ChatGPT’s swift and handy information retrieval supported autonomous learning on the topic. As an accessible and user-friendly tool, it saved considerable time. Moreover, its accessibility and constant availability helped in tailoring learning experiences to fit the learner’s schedule, independent of external factors or intermediaries. ChatGPT’s use of simple, everyday language, coupled with its capacity to deconstruct and elucidate complex concepts, rendered it exceedingly approachable and beneficial for information searches and for enhancing the accessibility of educational content. Lihi also acknowledged the efficacy of ChatGPT in facilitating the rapid acquisition and expansion of her conceptual knowledge. She underscored that the ChatGPT tool obviated the need to consult multiple databases and websites for extracting conceptual information: ChatGPT is really fast and easy to use when you need info on lots of different things. It’s great for finding technical stuff, explaining problems, understanding things better, and getting new ideas on the spot. You don’t even have to go looking for more sources – it’s all right there.

Data synthesis and analysis enhancement with ChatGPT

Analysis of the reflective journals indicates that students found the synthesis, editing, and analysis of content facilitated by ChatGPT to be extremely beneficial. The tool significantly reduced the technical complexity of gathering and synthesizing information from different sources, tasks that had previously been their responsibility. As a result, they were spared the need for synthesizing, editing, and analyzing the raw data, with ChatGPT efficiently performing these functions on their behalf. Meir wrote: ChatGPT really helped us out. It gave us a full picture of the whole process, including the good and bad parts, and how to handle them. We didn’t even need to look at any other info sources at that point .

Evaluation of information in ChatGPT Interaction

The streamlined data collection procedures enabled the students to engage in more advanced learning processes, such as distinguishing between facts and assumptions, differentiating critical from non-critical information, and developing arguments as they advanced to more complex stages. The students observed that although ChatGPT presented data objectively, it did not offer explicit arguments, thus requiring them to actively interpret and formulate their own positions regarding the dilemma and identify the foundational principles for their principal arguments. For example, Miri’s reflections highlighted her need to formulate and develop a stance on the dilemma, which compelled her to engage in critical assessment of the situation:

ChatGPT didn’t really point out which arguments were more important or less important. It kind of listed them all the same way, which made me decide for myself what to focus on. I had to pick the arguments I thought were key and then find evidence to back them up.

Furthermore, the students were asked to support their arguments with evidence from the academic literature, necessitating a thorough evaluation and critical analysis of the information. This process led them to make informed decisions and formulate solutions. In their reflective journals, students documented a cautious approach, emphasizing the need not to simply accept information as it is presented. Instead, they highlighted the importance of thoroughly evaluating the information’s accuracy. Amir similarly addressed this issue, noting his necessity to independently navigate the “thinking part” and acquire the skills to construct strong arguments or effectively employ academic resources: The chat didn’t really help me figure out what’s important and what’s not when I write. It also didn’t teach me how to make strong arguments or how to use academic stuff to back up my points.

User experiences with ChatGPT

This category refers to the qualitative data related to participants’ overall experiences, perceptions, and attitudes towards interacting with ChatGPT. The theme of user experiences is divided into three sub-themes: Time Efficiency using ChatGPT; Accessibility and Availability of ChatGPT; and User-Friendly Dynamics . Overall, analysis of the students’ reflective journals reveals broad agreement about ChatGPT’s user-friendliness and ease of use. Many students noted the chatbot’s intuitive interface and straightforward functionality, which made it accessible to those who may not be tech-savvy. This consensus highlights the effectiveness of ChatGPT as a tool that simplifies information acquisition and supports learning without the typical complexities associated with advanced technological tools.

Time efficiency using ChatGPT

In this sub-category, analysis of the student journals revealed the major time-saving benefits of using ChatGPT for various tasks. ChatGPT successfully eliminated the need for students to sift through numerous sources of information. By providing a straightforward way to understand a concept, grasp its implications, and gather information on complex dilemmas, ChatGPT demonstrated its efficiency in saving students’ time. Riad mentioned the significant time efficiency gained from using the tool, highlighting how it saved him considerable time: You can find out a lot about all sorts of things really quickly. The chat gives you detailed breakdowns and explanations, sorting everything into different arguments and topics; it saves you a lot of time.

Ali also referred to this point: I was not very familiar with the details of accreditation, including its benefits and challenges, but within minutes I was able to grasp its essence and understand the importance of the whole process.

The time efficiency extended not only to data retrieval and collection but also encompassed information synthesis, significantly reducing the amount of time usually required for comprehensive and coherent processing and reformulating of acquired data. Mai observed that the time saved was also because she didn’t need to search for data across multiple sources and combine it together:

The amount of time I save is insane. If I had to search for this stuff on the internet instead of using the chat, it would take me way longer to find an answer. And even after finding it, I’d have to summarize what I found and then rephrase it in my own words, which takes so much time.

Accessibility and availability of ChatGPT

A majority of the students noted that the tool’s immediate accessibility and availability significantly facilitated the personalization of learning approaches. This customization seamlessly interfaced with the unique scheduling needs of each learner, offering flexibility that in traditional learning settings is typically constrained by external factors or intermediaries. Hana highlighted ChatGPT’s anytime, anywhere accessibility through a simple interface, enabling quick and comprehensive responses without the wait for expert assistance: ChatGPT is available to use anytime, anywhere using a simple and convenient interface. This would allow you to get a quick and comprehensive response at any time of the day, without having to wait around for people or experts to help you out.

Lina similarly noted: It’s pretty great how available it is (as long as it’s not too busy…). Any question I have, I get an answer. It saved me a lot of Google searches and reading articles and stuff. I get a quick and clear answer to everything I ask and it’s all super fast.

ChatGPT Information credibility

This category involves instances where participants discuss the credibility, reliability, and trustworthiness of the information provided by ChatGPT. Analysis of the reflective journals showed that interaction with ChatGPT facilitated students’ ability to acquire fundamental knowledge, which could then be expanded upon through subsequent inquiries and verification. Nevertheless, as students proceeded in their tasks, particularly those that required articulating arguments and substantiating their stances on complex dilemmas, they acknowledged the limitations of relying solely on ChatGPT. These limitations focused primarily on concerns about the tool’s credibility in providing sufficiently authoritative information. In this regard, Ofri appreciated ChatGPT’s quick access to information but expressed concerns over its credibility and occasional inaccuracies, leading to unexpected disappointment:

I have found that ChatGPT has a lot of good points. It can quickly give you a lot of information on so many topics and you can really use that information. But I have also learned that this tool has its drawbacks. It is not always right, and it certainly doesn’t always give you things that are based on solid academic facts. Sometimes ChatGPT just makes things up. To be honest, realizing this was a bit of a shock to me.

Students also noted that they were often faced with an overwhelming amount of information, some of which was irrelevant or incorrect, requiring them to evaluate the information and determine its quality. Dalia noted that while ChatGPT provided extensive information initially, aiding in learning about the topic, it also required discernment to distinguish between accurate and less relevant information: In the first stage, the chat gave us a lot of information, which was great because it helped us learn more about the topic. But at the same time, we had to decide which information was really important and accurate and which wasn’t.

Students’ understanding of the limitations of relying solely on the information provided to justify arguments and articulate positions in dilemmas motivated them to examine and assess its reliability. They did so by asking specific questions and consulting established academic references. From the students’ point of view, this careful research and critical evaluation process not only provided them with the opportunity to refine their powers of critical thinking and analysis, it also equipped them with the capacity to critically evaluate the credibility of the information presented. Lina wrote:

I attempted to back up the info I found with academic sources, but then I figured out that the chat isn’t always reliable…. I went through each article that I got results from…to check where is it from, and whether the author actually existed or was just made up… After that, I did another check with other databases. This whole process made me super cautious and thorough in checking everything.

The students expressed unanimous agreement that the need to assess the information provided by the chat forced them to be critical and use evaluation skills. Not only was this a skill they needed to be able to put to good use. It also constituted a challenge in using ChatGPT, as Limor stated that, contrary to reducing critical thinking, proper use of ChatGPT can enhance it by prompting users to reconsider and verify information, despite the challenge:

It might seem that using ChatGPT would make you think less because, well, it’s like chatting to a robot. But actually, if you use it properly and really get into it, it adds a lot to your knowledge and makes you think more broadly and deeper. This is because it makes you think about things over and over again, and double-check the information… it wasn’t easy.

Challenges and barriers in Working with ChatGPT

This category encompasses the various obstacles, difficulties, and limitations encountered by participants while using ChatGPT, including technical issues, comprehension challenges, and frustration. The analysis suggests that despite the students’ widespread agreement on the advantages of using ChatGPT, such as its ease of use, constant availability, and user-friendliness, its accompanying challenges should also be considered. Among these challenges are hesitation in adopting new, cutting-edge technology, difficulties in learning how to use the tool, and language barriers. The language issue was particularly significant, as ChatGPT operates mainly in English, which is not the first language of many of the students. Shir faced difficulties with English translation but viewed it as an opportunity to improve language skills, eventually becoming more comfortable with the chat and reducing reliance on outside translation help:

One big problem I had was writing in English and then translating it to express what I wanted to say. But I decided to take it on as a challenge and use it as a chance to improve my reading and writing in English. Since we didn’t have to use English much, at first it felt like it took forever to understand or read stuff. But gradually, we got the hang of the chat and didn’t need as much help with translating from outside sources.

Some students noted that they also faced some technical issues, revealing the downside of depending exclusively on online tools for studying. For many students, this was their first time using AI including applications like ChatGPT that are built on large language models. As they continued to use it, however, they became more accustomed to it. Ali found initially accessing the GPT chat difficult and, despite its ease of use, experienced issues with site access due to high traffic and occasional freezing, hindering continuous use:

When I first tried the GPT chat for my task, it was a bit tough to get onto the site. But after a while, I noticed that even though the chat is easy to use, it’s got its problems. Sometimes, you can’t even get into the chat because too many people are trying to use it at the same time, and other times, it just freezes up, and you can’t keep using it.

Mastering ChatGPT-Prompting competency

This category involves instances where participants demonstrate proficiency in formulating effective prompts and questions to elicit accurate and relevant responses from ChatGPT. Analysis of the reflective journals revealed that this theme posed a notable challenge for the students, primarily due to their unfamiliarity with the tool. Indeed, they needed to learn how to use the chat effectively to elicit the correct responses and achieve their desired outcomes. Additionally, they encountered challenges in ensuring accuracy and setting the right parameters to establish a reliable and precise database. Despite these obstacles, the students recognized that their efforts to achieve accuracy and their practice of asking repetitive questions were instrumental in developing higher-order thinking skills and being able to organize and manage the required information proficiently. Liya related to this challenge by noted that dealing with inaccurate responses from the model involves clarifying questions with more details, considering alternative answers, and emphasizing the importance of verifying the information received:

Sometimes the model may give you wrong information or answers… to cope with getting answers that are not accurate, you should make your question clearer and add more details. Also think about using different choices of answers. And it is really important to always check the answers you’re getting.

Analysis of the reflective journals showed that systematic demonstration of these activities, along with comprehensive detailing of early learning stages and the cumulative nature of the tasks, provided students the chance to assess and revisit each step retrospectively. This reflective review allowed them to seek explanations for any aspects that were unclear, ask more questions and craft more targeted prompts, and gain a deeper understanding of the entire process. Rim, for example, explained: The chat lets us get information in a series, like being able to ask another question to get a better understanding or clear up something from the first questions we asked. This helped us keep track of everything by linking all our questions together.

Nir noted that the need to aim for accuracy by repeatedly refining the questions really helped in dealing with the assigned tasks effectively:

From my experience with ChatGPT, I have learned that if you want good answers, you have to be really clear about what you are asking. You need to know what you want to achieve with the chat. It is best to give specific instructions to obtain the exact info you need. Also, you should think carefully about the answers you get, making sure the facts are right, and using your own thinking to make wise decisions.

This qualitative study examined the process of introducing and using a pedagogical framework that integrates problem-based learning with the use of ChatGPT among undergraduate healthcare management students. The study also provided a qualitative exploration of their experiences using this technology and assessed how the use of ChatGPT can shift the focus from traditional digital literacy skills to advanced AI literacy skills. It demonstrated how the use of the ChatGPT platform can be managed to encourage the development of critical thinking and evaluation skills through active student engagement. These skills are considered critical for learning and working with AI platforms.

The analysis of students’ reflective journals indicated a perception of the platform as user-friendly. Minichiello et al. [ 54 ] expand the definition of “user experience” beyond mere interaction with user interfaces to include design, information presentation, technological features, and factors related to emotion, personal connection, and experience. Students described their experience with the platform positively, citing it as an incentive for ongoing engagement.

The analysis also showed that the platform’s efficiency was significantly influenced by its high availability and accessibility, which were key factors in its attractiveness to users. This attractiveness was further enhanced by its ease of use. A critical aspect of the platform’s effectiveness was its efficiency in providing key materials in a timely manner, drastically reducing the time required to retrieve information. Users particularly appreciated this aspect of the platform as it streamlined their access to information and significantly improved their learning efficiency. The platform’s ability to deliver relevant information quickly and efficiently was instrumental in its positive reception. In an academic environment where efficient time management and quick access to educational materials are essential, the platform’s ability to meet these needs effectively constituted a notable advantage.

However, students noted initial difficulties and obstacles in utilizing ChatGPT, primarily related to data credibility. These challenges, highlighted in the qualitative data, necessitated the application of critical thinking and conducting various checks to verify the information received. This concern over the credibility of information from AI tools aligns with observations by Mohamad-Hani et al. [ 55 ], who reported similar credibility issues with ChatGPT data among healthcare professionals.

Another significant challenge for the students focused on how to retrieve relevant and accurate information. To this end, they had to refine their question formulation to extract the most relevant and accurate data from the tool. Such challenges have increasingly become a focus of academic attention due to the emerging recognition of the importance of developing prompting skills for effective interaction with platforms such as ChatGPT and other AI tools [ 19 , 20 ].

In terms of digital literacy skills, the findings of this study suggest that basic literacy skills such as locating, retrieving, synthesizing, and summarizing information may become less important as AI systems improve. Yet students still must be trained to evaluate and think critically about AI tools and what they can accomplish, especially since AI technologies like ChatGPT are not always completely trustworthy. Therefore, students need to learn how to evaluate the information these tools provide. These findings also offer some support for the notion that while digital literacy is undeniably recognized as crucial for the 21st century, especially in the healthcare arena [ 36 , 45 ], the definition of digital literacy is changing as technological tools develop. For decades, education focused on developing basic skills. Over time, however, there was a shift toward the cultivation of more complex skills involving information evaluation, synthesis, and assessment [ 56 , 57 ]. Yet as AI continues to penetrate everyday life, there has been a noticeable evolution in the forms of literacy required.

This evolution marks a transition from traditional data digital literacy, which emphasizes a basic understanding and processing of information, to AI digital literacy, which goes beyond mere data consumption to include using digital tools skillfully, understanding the nature of digital content, and effectively navigating the complex digital landscape. This shift reflects the changing demands of a technology-driven society, in which digital literacy is becoming increasingly essential for both personal and professional development [ 58 ]. As AI becomes integrated into different dimensions of work and daily life, especially in the healthcare industry, AI digital literacy will continue to evolve to meet the new demands. This will require a different set of skills, including prompting skills that allow users to better interact with AI tools [ 19 , 20 ].

These results highlight the importance of rethinking the educational use of AI tools such as ChatGPT, potentially leading to changes in future learning curricula. Without the ability to use digital tools, students are liable to fall behind when it comes to adapting to new technologies, thus limiting their ability to learn key skills. Therefore, AI tools must be taught and used in a way that supports students’ holistic learning. These findings align with those of other researchers who focus on the use of the AI platform in education [ 40 , 42 , 43 ]. Such an approach will ensure that students are prepared for the evolving challenges and opportunities of our increasingly digital world. This is especially important in the medical education field, as AI is increasingly being used in different ways to improve the accuracy of disease diagnosis, treatment strategies, and prediction of patient outcomes [ 9 , 10 , 25 , 27 ].

Given that AI technology is still developing and is anticipated to advance and become more widely used [ 21 , 22 ], the need to adapt and acquire new literacy skills is growing. As AI evolves, reliance on traditional basic skills may decline over time, underscoring the importance of learning how to effectively utilize and interact with emerging technologies. Learning to engage with AI tools such as ChatGPT from an early stage in their education can greatly enhance students’ learning experiences. This early exposure will not only provide them with a deeper understanding of these tools. It will also boost their motivation to learn how to use them more effectively, thus highlighting the importance of training students to handle such technologies proficiently. Equally important is the need to guide students through these learning processes to ensure they acquire the necessary skills and knowledge to navigate and utilize AI tools successfully in their educational journey [ 11 ].

Limitations and future research directions

This study utilized a pedagogical framework that integrates problem-based learning with the use of ChatGPT. While the researcher focused on the pedagogical aspect, future research is warranted to compare this digitally supported activity to a non-digital equivalent and examine the impact on students’ literacy and skills. Such a comparison would make it possible to assess what the digital instrument contributes to skill development and to identify any challenges encountered.

The use of this tool across different teaching methods could also be explored to determine whether it is particularly effective for certain types of tasks or requirements. The current study focused on health management. Implementation of this teaching approach in other academic areas should be examined to assess its effectiveness in acquiring competencies in different arenas. The findings of this study highlight the need for further research into the use of AI in learning environments that focus on goal-oriented pedagogy. Such research can help in developing educational strategies that promote the skills essential for lifelong learning.

Conclusions and recommendations

In conclusion, revisiting the research questions in the context of our findings highlights the transformative potential of integrating ChatGPT with problem-based learning in healthcare management education. This study underscores how such integration not only shifts the focus from traditional digital literacy to advanced AI literacy skills but also enhances critical thinking and evaluation capabilities among students. These competencies are indispensable as AI continues to reshape the landscape of healthcare and medical education. AI is emerging as a transformative force that will fundamentally change the global landscape. Although we are still in the early stages of integrating and understanding AI capabilities, its potential to shape our future is clear. Adapting to this digital transformation, especially in healthcare, is crucial [ 4 , 6 ].

Integrating AI into healthcare systems poses significant challenges and raises many unanswered questions [ 9 , 10 ]. These issues require careful consideration and strategic planning to maximize benefits while addressing implementation complexities. The extent and impact of these transformations on the health system and its workforce remain uncertain. However, it is crucial to prepare for these changes at both individual and organizational levels. Educational institutions must update their teaching methods to meet digital demands, recognizing the critical role of educators in developing effective support strategies.

To enable healthcare professionals to integrate AI tools effectively, these tools should be introduced early in education, such as during undergraduate studies or initial professional training [ 9 , 32 , 33 ]. Hands-on experience allows learners to build confidence and understand the tools’ limitations. Additionally, AI tools and especially LLMs such as GPT and their applications, including platforms like ChatGPT, can serve as user-friendly and efficient learning aids, as demonstrated in this research. In addition, researchers should strive to develop innovative pedagogical methods for integrating these tools into different curricula, as exemplified here by the effective use of dilemma-based learning enhanced by ChatGPT. These studies should focus on determining which skills will become redundant and on highlighting essential competencies needed for AI literacy, including prompting, evaluation skills, and critical thinking, all of which are essential for effectively integrating AI and LLMs into medical education and daily practice. Participants in such studies have noted that the acquisition of such skills, particularly in the area of effective prompting, significantly improves the quality of AI responses. Similar to learning a new language, learning to use AI requires precise phrasing and an in-depth understanding of context. Not only will AI skills improve student engagement and comprehension, they will also encourage critical thinking, leading to better educational outcomes. Students who formulate well-structured search queries obtain more accurate responses from AI, which are critical to improving healthcare and learning outcomes.

It is therefore imperative that academia and higher education institutions, including medical education institutions, adopt methods for effectively guiding and training students in using AI. This approach is essential to address the evolving global educational landscape and to embrace the shift in roles. Educators should move from being primarily providers of knowledge to being facilitators of cultural understanding and skill development. Such a shift is essential to promote the transformative evolution of the role of educators in the modern educational context.

Availability of data and materials

Data are available upon request from the Corresponding author.

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Problem based learning in medical education

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• 1 Department of Anatomy, Dhulikhel Hospita-Kathmandu University Hospital, Kathmandu University School of Medical Sciences.
• PMID: 23575059
• DOI: 10.3126/kumj.v10i4.11002

Problem based learning, originally introduced in the Medical School at Mc-Master University in Canada in the late 1960s, and is now being used as a learning method in many medical schools in the United Kingdom and worldwide. Problem based learning have been adapted in many medical colleges of Nepal be used either as the mainstay of an entire curriculum or for the delivery of individual courses. Institution of Medicine, Tribhuvan University in 1980, BP Koirala Institute of Health Sciences at Dharan in 1999, KUSMS with the great support of faculties from Harvard University in 2001, Patan Academy of Health Sciences (PAHS), and lately all the affiliated medical colleges of Kathmandu University have adapted Problem based learning.

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Project-Based Learning Adapted as a Physiology Teaching Strategy for the Sophomore Undergraduate Medical Students

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• Published: 06 June 2024

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• Luís Henrique Montrezor   ORCID: orcid.org/0000-0003-1022-3358 1 , 2 , 3 , 4 &
• Camila Linhares Taxini Passos 1  

Project-based learning (PBL) is a teaching strategy in which students work as a group to identify a problem and discuss ideas for its solution. It is an educational approach to teaching and learning that involves groups of students working together to solve a problem, complete a task, or even create a product based on a project. It places the student at the center of the teaching–learning process and stimulates their engagement to transform learning into knowledge.

The aim of the present study was to use an adapted PBL approach as a physiology teaching strategy for sophomore medical students. For this, at the end of the semester, 148 students were organized in groups and were instructed to develop projects on the topics of cardiorespiratory physiology and metabolic physiology. Evaluation was made of the development and presentation of the projects, comparing the grades with those obtained in tests taken individually by the students at the beginning of the semester. The opinions of the students about the strategy were analyzed using a questionnaire answered individually. The results showed that different strategies were developed by the students to present their projects, notably employing question and answer board games, card games, and videos simulating interviews with clinicians. The mean scores for the collaborative group activities were significantly higher than for the tests performed individually by the students. The answers given in the opinion questionnaire indicated that most of the students considered the strategy useful for their learning, since it stimulated research, study, and discussion on the topics studied. Most of the students believed that working as a group was beneficial and that the time allocated for the project development was sufficient.

Therefore, use of the adapted project-based learning as a physiology teaching strategy was viewed positively by the students and improved their performance in learning about cardiorespiratory and metabolic physiology.

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Department of Biological Science and Health – Medicine, University of Araraquara - UNIARA, Rua Carlos Gomes, 1217, Araraquara, SP, 14801-340, Brazil

Luís Henrique Montrezor & Camila Linhares Taxini Passos

Medicinal Chemistry and Regenerative Medicine Group, QUIMMERA – UNIARA, Araraquara, SP, Brazil

Luís Henrique Montrezor

Brazilian Society of Physiology (SBFis), Undergraduate Education Committee, São Paulo, SP, Brazil

Study and Research Group in University Pedagogy – GEPPU, São Paulo State University – UNESP, Rio Claro, SP, Brazil

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LHM and CLTP conceived, designed research, and performed experiments; CLTP analyzed data; LHM and CLTP interpreted results of the experiments; LHM prepared figures and drafted the manuscript; LHM and CLTP edited and revised the manuscript; LHM and CLTP approved the final version of the manuscript.

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Correspondence to Luís Henrique Montrezor .

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Some results, specifically the opinions of the students regarding the evaluation activity involving collaborative groups, adapted from the project-based learning teaching strategy, were presented as a poster at the 60th Brazilian Congress of Medical Education (COBEM, November 3–6, 2022) held in Foz do Iguaçu, Brazil. This work received an award for being the most commented poster.

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Montrezor, L.H., Passos, C.L.T. Project-Based Learning Adapted as a Physiology Teaching Strategy for the Sophomore Undergraduate Medical Students. Med.Sci.Educ. (2024). https://doi.org/10.1007/s40670-024-02092-y

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Positive thinking: Stop negative self-talk to reduce stress

Positive thinking helps with stress management and can even improve your health. Practice overcoming negative self-talk with examples provided.

Is your glass half-empty or half-full? How you answer this age-old question about positive thinking may reflect your outlook on life, your attitude toward yourself, and whether you're optimistic or pessimistic — and it may even affect your health.

Indeed, some studies show that personality traits such as optimism and pessimism can affect many areas of your health and well-being. The positive thinking that usually comes with optimism is a key part of effective stress management. And effective stress management is associated with many health benefits. If you tend to be pessimistic, don't despair — you can learn positive thinking skills.

Understanding positive thinking and self-talk

Positive thinking doesn't mean that you ignore life's less pleasant situations. Positive thinking just means that you approach unpleasantness in a more positive and productive way. You think the best is going to happen, not the worst.

Positive thinking often starts with self-talk. Self-talk is the endless stream of unspoken thoughts that run through your head. These automatic thoughts can be positive or negative. Some of your self-talk comes from logic and reason. Other self-talk may arise from misconceptions that you create because of lack of information or expectations due to preconceived ideas of what may happen.

If the thoughts that run through your head are mostly negative, your outlook on life is more likely pessimistic. If your thoughts are mostly positive, you're likely an optimist — someone who practices positive thinking.

The health benefits of positive thinking

Researchers continue to explore the effects of positive thinking and optimism on health. Health benefits that positive thinking may provide include:

• Increased life span
• Lower rates of depression
• Lower levels of distress and pain
• Greater resistance to illnesses
• Better psychological and physical well-being
• Better cardiovascular health and reduced risk of death from cardiovascular disease and stroke
• Reduced risk of death from cancer
• Reduced risk of death from respiratory conditions
• Reduced risk of death from infections
• Better coping skills during hardships and times of stress

It's unclear why people who engage in positive thinking experience these health benefits. One theory is that having a positive outlook enables you to cope better with stressful situations, which reduces the harmful health effects of stress on your body.

It's also thought that positive and optimistic people tend to live healthier lifestyles — they get more physical activity, follow a healthier diet, and don't smoke or drink alcohol in excess.

Identifying negative thinking

Not sure if your self-talk is positive or negative? Some common forms of negative self-talk include:

• Filtering. You magnify the negative aspects of a situation and filter out all the positive ones. For example, you had a great day at work. You completed your tasks ahead of time and were complimented for doing a speedy and thorough job. That evening, you focus only on your plan to do even more tasks and forget about the compliments you received.
• Personalizing. When something bad occurs, you automatically blame yourself. For example, you hear that an evening out with friends is canceled, and you assume that the change in plans is because no one wanted to be around you.
• Catastrophizing. You automatically anticipate the worst without facts that the worse will happen. The drive-through coffee shop gets your order wrong, and then you think that the rest of your day will be a disaster.
• Blaming. You try to say someone else is responsible for what happened to you instead of yourself. You avoid being responsible for your thoughts and feelings.
• Saying you "should" do something. You think of all the things you think you should do and blame yourself for not doing them.
• Magnifying. You make a big deal out of minor problems.
• Perfectionism. Keeping impossible standards and trying to be more perfect sets yourself up for failure.
• Polarizing. You see things only as either good or bad. There is no middle ground.

Focusing on positive thinking

You can learn to turn negative thinking into positive thinking. The process is simple, but it does take time and practice — you're creating a new habit, after all. Following are some ways to think and behave in a more positive and optimistic way:

• Identify areas to change. If you want to become more optimistic and engage in more positive thinking, first identify areas of your life that you usually think negatively about, whether it's work, your daily commute, life changes or a relationship. You can start small by focusing on one area to approach in a more positive way. Think of a positive thought to manage your stress instead of a negative one.
• Check yourself. Periodically during the day, stop and evaluate what you're thinking. If you find that your thoughts are mainly negative, try to find a way to put a positive spin on them.
• Be open to humor. Give yourself permission to smile or laugh, especially during difficult times. Seek humor in everyday happenings. When you can laugh at life, you feel less stressed.
• Follow a healthy lifestyle. Aim to exercise for about 30 minutes on most days of the week. You can also break it up into 5- or 10-minute chunks of time during the day. Exercise can positively affect mood and reduce stress. Follow a healthy diet to fuel your mind and body. Get enough sleep. And learn techniques to manage stress.
• Surround yourself with positive people. Make sure those in your life are positive, supportive people you can depend on to give helpful advice and feedback. Negative people may increase your stress level and make you doubt your ability to manage stress in healthy ways.
• Practice positive self-talk. Start by following one simple rule: Don't say anything to yourself that you wouldn't say to anyone else. Be gentle and encouraging with yourself. If a negative thought enters your mind, evaluate it rationally and respond with affirmations of what is good about you. Think about things you're thankful for in your life.

Here are some examples of negative self-talk and how you can apply a positive thinking twist to them:

Practicing positive thinking every day

If you tend to have a negative outlook, don't expect to become an optimist overnight. But with practice, eventually your self-talk will contain less self-criticism and more self-acceptance. You may also become less critical of the world around you.

When your state of mind is generally optimistic, you're better able to handle everyday stress in a more constructive way. That ability may contribute to the widely observed health benefits of positive thinking.

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• Forte AJ, et al. The impact of optimism on cancer-related and postsurgical cancer pain: A systematic review. Journal of Pain and Symptom Management. 2021; doi:10.1016/j.jpainsymman.2021.09.008.
• Rosenfeld AJ. The neuroscience of happiness and well-being. Child and Adolescent Psychiatric Clinics of North America. 2019;28:137.
• Kim ES, et al. Optimism and cause-specific mortality: A prospective cohort study. American Journal of Epidemiology. 2016; doi:10.1093/aje/kww182.
• Amonoo HL, et al. Is optimism a protective factor for cardiovascular disease? Current Cardiology Reports. 2021; doi:10.1007/s11886-021-01590-4.
• Physical Activity Guidelines for Americans. 2nd ed. U.S. Department of Health and Human Services. https://health.gov/paguidelines/second-edition. Accessed Oct. 20, 2021.
• Seaward BL. Essentials of Managing Stress. 4th ed. Burlington, Mass.: Jones & Bartlett Learning; 2021.
• Seaward BL. Cognitive restructuring: Reframing. Managing Stress: Principles and Strategies for Health and Well-Being. 8th ed. Burlington, Mass.: Jones & Bartlett Learning; 2018.
• Olpin M, et al. Stress Management for Life. 5th ed. Cengage Learning; 2020.
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How To Start A Business In 11 Steps (2024 Guide)

Updated: Apr 7, 2024, 1:44pm

Table of Contents

Before you begin: get in the right mindset, 1. determine your business concept, 2. research your competitors and market, 3. create your business plan, 4. choose your business structure, 5. register your business and get licenses, 6. get your finances in order, 7. fund your business, 8. apply for business insurance, 9. get the right business tools, 10. market your business, 11. scale your business, what are the best states to start a business, bottom line, frequently asked questions (faqs).

Starting a business is one of the most exciting and rewarding experiences you can have. But where do you begin? There are several ways to approach creating a business, along with many important considerations. To help take the guesswork out of the process and improve your chances of success, follow our comprehensive guide on how to start a business. We’ll walk you through each step of the process, from defining your business idea to registering, launching and growing your business.

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The public often hears about overnight successes because they make for a great headline. However, it’s rarely that simple—they don’t see the years of dreaming, building and positioning before a big public launch. For this reason, remember to focus on your business journey and don’t measure your success against someone else’s.

Consistency Is Key

New business owners tend to feed off their motivation initially but get frustrated when that motivation wanes. This is why it’s essential to create habits and follow routines that power you through when motivation goes away.

Take the Next Step

Some business owners dive in headfirst without looking and make things up as they go along. Then, there are business owners who stay stuck in analysis paralysis and never start. Perhaps you’re a mixture of the two—and that’s right where you need to be. The best way to accomplish any business or personal goal is to write out every possible step it takes to achieve the goal. Then, order those steps by what needs to happen first. Some steps may take minutes while others take a long time. The point is to always take the next step.

Most business advice tells you to monetize what you love, but it misses two other very important elements: it needs to be profitable and something you’re good at. For example, you may love music, but how viable is your business idea if you’re not a great singer or songwriter? Maybe you love making soap and want to open a soap shop in your small town that already has three close by—it won’t be easy to corner the market when you’re creating the same product as other nearby stores.

If you don’t have a firm idea of what your business will entail, ask yourself the following questions:

• What do you love to do?
• What do you hate to do?
• Can you think of something that would make those things easier?
• What are you good at?
• What do others come to you for advice about?
• If you were given ten minutes to give a five-minute speech on any topic, what would it be?
• What’s something you’ve always wanted to do, but lacked resources for?

These questions can lead you to an idea for your business. If you already have an idea, they might help you expand it. Once you have your idea, measure it against whether you’re good at it and if it’s profitable.

Your business idea also doesn’t have to be the next Scrub Daddy or Squatty Potty. Instead, you can take an existing product and improve upon it. You can also sell a digital product so there’s little overhead.

What Kind of Business Should You Start?

Before you choose the type of business to start, there are some key things to consider:

• What type of funding do you have?
• How much time do you have to invest in your business?
• Do you prefer to work from home or at an office or workshop?
• What interests and passions do you have?
• Can you sell information (such as a course), rather than a product?
• What skills or expertise do you have?
• How fast do you need to scale your business?
• What kind of support do you have to start your business?
• Are you partnering with someone else?
• Does the franchise model make more sense to you?

Consider Popular Business Ideas

Not sure what business to start? Consider one of these popular business ideas:

• Start a Franchise
• Start a Blog
• Start an Online Store
• Start a Dropshipping Business
• Start a Cleaning Business
• Start a Bookkeeping Business
• Start a Clothing Business
• Start a Landscaping Business
• Start a Consulting Business
• Start a Photography Business
• Start a Vending Machine Business

Most entrepreneurs spend more time on their products than they do getting to know the competition. If you ever apply for outside funding, the potential lender or partner wants to know: what sets you (or your business idea) apart? If market analysis indicates your product or service is saturated in your area, see if you can think of a different approach. Take housekeeping, for example—rather than general cleaning services, you might specialize in homes with pets or focus on garage cleanups.

Primary Research

The first stage of any competition study is primary research, which entails obtaining data directly from potential customers rather than basing your conclusions on past data. You can use questionnaires, surveys and interviews to learn what consumers want. Surveying friends and family isn’t recommended unless they’re your target market. People who say they’d buy something and people who do are very different. The last thing you want is to take so much stock in what they say, create the product and flop when you try to sell it because all of the people who said they’d buy it don’t because the product isn’t something they’d buy.

Secondary Research

Utilize existing sources of information, such as census data, to gather information when you do secondary research. The current data may be studied, compiled and analyzed in various ways that are appropriate for your needs but it may not be as detailed as primary research.

Conduct a SWOT Analysis

SWOT stands for strengths, weaknesses, opportunities and threats. Conducting a SWOT analysis allows you to look at the facts about how your product or idea might perform if taken to market, and it can also help you make decisions about the direction of your idea. Your business idea might have some weaknesses that you hadn’t considered or there may be some opportunities to improve on a competitor’s product.

Asking pertinent questions during a SWOT analysis can help you identify and address weaknesses before they tank your new business.

A business plan is a dynamic document that serves as a roadmap for establishing a new business. This document makes it simple for potential investors, financial institutions and company management to understand and absorb. Even if you intend to self-finance, a business plan can help you flesh out your idea and spot potential problems. When writing a well-rounded business plan, include the following sections:

• Executive summary: The executive summary should be the first item in the business plan, but it should be written last. It describes the proposed new business and highlights the goals of the company and the methods to achieve them.
• Company description: The company description covers what problems your product or service solves and why your business or idea is best. For example, maybe your background is in molecular engineering, and you’ve used that background to create a new type of athletic wear—you have the proper credentials to make the best material.
• Market analysis: This section of the business plan analyzes how well a company is positioned against its competitors. The market analysis should include target market, segmentation analysis, market size, growth rate, trends and a competitive environment assessment.
• Organization and structure: Write about the type of business organization you expect, what risk management strategies you propose and who will staff the management team. What are their qualifications? Will your business be a single-member limited liability company (LLC) or a corporation ?
• Mission and goals: This section should contain a brief mission statement and detail what the business wishes to accomplish and the steps to get there. These goals should be SMART (specific, measurable, action-orientated, realistic and time-bound).
• Products or services: This section describes how your business will operate. It includes what products you’ll offer to consumers at the beginning of the business, how they compare to existing competitors, how much your products cost, who will be responsible for creating the products, how you’ll source materials and how much they cost to make.
• Background summary: This portion of the business plan is the most time-consuming to write. Compile and summarize any data, articles and research studies on trends that could positively and negatively affect your business or industry.
• Marketing plan: The marketing plan identifies the characteristics of your product or service, summarizes the SWOT analysis and analyzes competitors. It also discusses how you’ll promote your business, how much money will be spent on marketing and how long the campaign is expected to last.
• Financial plan: The financial plan is perhaps the core of the business plan because, without money, the business will not move forward. Include a proposed budget in your financial plan along with projected financial statements, such as an income statement, a balance sheet and a statement of cash flows. Usually, five years of projected financial statements are acceptable. This section is also where you should include your funding request if you’re looking for outside funding.

Learn more: Download our free simple business plan template .

Come Up With an Exit Strategy

An exit strategy is important for any business that is seeking funding because it outlines how you’ll sell the company or transfer ownership if you decide to retire or move on to other projects. An exit strategy also allows you to get the most value out of your business when it’s time to sell. There are a few different options for exiting a business, and the best option for you depends on your goals and circumstances.

The most common exit strategies are:

• Selling the business to another party
• Passing the business down to family members
• Liquidating the business assets
• Closing the doors and walking away

Develop a Scalable Business Model

As your small business grows, it’s important to have a scalable business model so that you can accommodate additional customers without incurring additional costs. A scalable business model is one that can be replicated easily to serve more customers without a significant increase in expenses.

Some common scalable business models are:

• Subscription-based businesses
• Businesses that sell digital products
• Franchise businesses
• Network marketing businesses

Start Planning for Taxes

One of the most important things to do when starting a small business is to start planning for taxes. Taxes can be complex, and there are several different types of taxes you may be liable for, including income tax, self-employment tax, sales tax and property tax. Depending on the type of business you’re operating, you may also be required to pay other taxes, such as payroll tax or unemployment tax.

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When structuring your business, it’s essential to consider how each structure impacts the amount of taxes you owe, daily operations and whether your personal assets are at risk.

An LLC limits your personal liability for business debts. LLCs can be owned by one or more people or companies and must include a registered agent . These owners are referred to as members.

• LLCs offer liability protection for the owners
• They’re one of the easiest business entities to set up
• You can have a single-member LLC
• You may be required to file additional paperwork with your state on a regular basis
• LLCs can’t issue stock
• You’ll need to pay annual filing fees to your state

Limited Liability Partnership (LLP)

An LLP is similar to an LLC but is typically used for licensed business professionals such as an attorney or accountant. These arrangements require a partnership agreement.

• Partners have limited liability for the debts and actions of the LLP
• LLPs are easy to form and don’t require much paperwork
• There’s no limit to the number of partners in an LLP
• Partners are required to actively take part in the business
• LLPs can’t issue stock
• All partners are personally liable for any malpractice claims against the business

Sole Proprietorship

If you start a solo business, you might consider a sole proprietorship . The company and the owner, for legal and tax purposes, are considered the same. The business owner assumes liability for the business. So, if the business fails, the owner is personally and financially responsible for all business debts.

• Sole proprietorships are easy to form
• There’s no need to file additional paperwork with your state
• You’re in complete control of the business
• You’re personally liable for all business debts
• It can be difficult to raise money for a sole proprietorship
• The business may have a limited lifespan

Corporation

A corporation limits your personal liability for business debts just as an LLC does. A corporation can be taxed as a C corporation (C-corp) or an S corporation (S-corp). S-corp status offers pass-through taxation to small corporations that meet certain IRS requirements. Larger companies and startups hoping to attract venture capital are usually taxed as C-corps.

• Corporations offer liability protection for the owners
• The life span of a corporation is not limited
• A corporation can have an unlimited number of shareholders
• Corporations are subject to double taxation
• They’re more expensive and complicated to set up than other business structures
• The shareholders may have limited liability

Before you decide on a business structure, discuss your situation with a small business accountant and possibly an attorney, as each business type has different tax treatments that could affect your bottom line.

Helpful Resources

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There are several legal issues to address when starting a business after choosing the business structure. The following is a good checklist of items to consider when establishing your business:

Choose Your Business Name

Make it memorable but not too difficult. Choose the same domain name, if available, to establish your internet presence. A business name cannot be the same as another registered company in your state, nor can it infringe on another trademark or service mark that is already registered with the United States Patent and Trademark Office (USPTO).

Business Name vs. DBA

There are business names, and then there are fictitious business names known as “Doing Business As” or DBA. You may need to file a DBA if you’re operating under a name that’s different from the legal name of your business. For example, “Mike’s Bike Shop” is doing business as “Mike’s Bikes.” The legal name of the business is “Mike’s Bike Shop,” and “Mike’s Bikes” is the DBA.

You may need to file a DBA with your state, county or city government offices. The benefits of a DBA include:

• It can help you open a business bank account under your business name
• A DBA can be used as a “trade name” to brand your products or services
• A DBA can be used to get a business license

Register Your Business and Obtain an EIN

You’ll officially create a corporation, LLC or other business entity by filing forms with your state’s business agency―usually the Secretary of State. As part of this process, you’ll need to choose a registered agent to accept legal documents on behalf of your business. You’ll also pay a filing fee. The state will send you a certificate that you can use to apply for licenses, a tax identification number (TIN) and business bank accounts.

Next, apply for an employer identification number (EIN) . All businesses, other than sole proprietorships with no employees, must have a federal employer identification number. Submit your application to the IRS and you’ll typically receive your number in minutes.

Get Appropriate Licenses and Permits

Legal requirements are determined by your industry and jurisdiction. Most businesses need a mixture of local, state and federal licenses to operate. Check with your local government office (and even an attorney) for licensing information tailored to your area.

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Open a Business Bank Account

Keep your business and personal finances separate. Here’s how to choose a business checking account —and why separate business accounts are essential. When you open a business bank account, you’ll need to provide your business name and your business tax identification number (EIN). This business bank account can be used for your business transactions, such as paying suppliers or invoicing customers. Most times, a bank will require a separate business bank account to issue a business loan or line of credit.

Hire a Bookkeeper or Get Accounting Software

If you sell a product, you need an inventory function in your accounting software to manage and track inventory. The software should have ledger and journal entries and the ability to generate financial statements.

Some software programs double as bookkeeping tools. These often include features such as check writing and managing receivables and payables. You can also use this software to track your income and expenses, generate invoices, run reports and calculate taxes.

There are many bookkeeping services available that can do all of this for you, and more. These services can be accessed online from any computer or mobile device and often include features such as bank reconciliation and invoicing. Check out the best accounting software for small business, or see if you want to handle the bookkeeping yourself.

Determine Your Break-Even Point

Before you fund your business, you must get an idea of your startup costs. To determine these, make a list of all the physical supplies you need, estimate the cost of any professional services you will require, determine the price of any licenses or permits required to operate and calculate the cost of office space or other real estate. Add in the costs of payroll and benefits, if applicable.

Businesses can take years to turn a profit, so it’s better to overestimate the startup costs and have too much money than too little. Many experts recommend having enough cash on hand to cover six months of operating expenses.

When you know how much you need to get started with your business, you need to know the point at which your business makes money. This figure is your break-even point.

In contrast, the contribution margin = total sales revenue – cost to make product

For example, let’s say you’re starting a small business that sells miniature birdhouses for fairy gardens. You have determined that it will cost you $500 in startup costs. Your variable costs are $0.40 per birdhouse produced, and you sell them for $1.50 each.

Let’s write these out so it’s easy to follow:

This means that you need to sell at least 456 units just to cover your costs. If you can sell more than 456 units in your first month, you will make a profit.

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There are many different ways to fund your business—some require considerable effort, while others are easier to obtain. Two categories of funding exist: internal and external.

Internal funding includes:

• Personal savings
• Credit cards
• Funds from friends and family

If you finance the business with your own funds or with credit cards, you have to pay the debt on the credit cards and you’ve lost a chunk of your wealth if the business fails. By allowing your family members or friends to invest in your business, you are risking hard feelings and strained relationships if the company goes under. Business owners who want to minimize these risks may consider external funding.

External funding includes:

• Small business loans
• Small business grants
• Angel investors
• Venture capital
• Crowdfunding

Small businesses may have to use a combination of several sources of capital. Consider how much money is needed, how long it will take before the company can repay it and how risk-tolerant you are. No matter which source you use, plan for profit. It’s far better to take home six figures than make seven figures and only keep $80,000 of it.

Funding ideas include:

• Invoice factoring: With invoice factoring , you can sell your unpaid invoices to a third party at a discount.
• Business lines of credit: Apply for a business line of credit , which is similar to a personal line of credit. The credit limit and interest rate will be based on your business’s revenue, credit score and financial history.
• Equipment financing: If you need to purchase expensive equipment for your business, you can finance it with a loan or lease.
• Small Business Administration (SBA) microloans: Microloans are up to $50,000 loans that can be used for working capital, inventory or supplies and machinery or equipment.
• Grants: The federal government offers grants for businesses that promote innovation, export growth or are located in historically disadvantaged areas. You can also find grants through local and regional organizations.
• Crowdfunding: With crowdfunding , you can raise money from a large group of people by soliciting donations or selling equity in your company.

Choose the right funding source for your business by considering the amount of money you need, the time frame for repayment and your tolerance for risk.

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You need to have insurance for your business , even if it’s a home-based business or you don’t have any employees. The type of insurance you need depends on your business model and what risks you face. You might need more than one type of policy, and you might need additional coverage as your business grows. In most states, workers’ compensation insurance is required by law if you have employees.

Work With an Agent To Get Insured

An insurance agent can help determine what coverages are appropriate for your business and find policies from insurers that offer the best rates. An independent insurance agent represents several different insurers, so they can shop around for the best rates and coverage options.

Basic Types of Business Insurance Coverage

• Liability insurance protects your business against third-party claims of bodily injury, property damage and personal injury such as defamation or false advertising.
• Property insurance covers the physical assets of your business, including your office space, equipment and inventory.
• Business interruption insurance pays for the loss of income if your business is forced to close temporarily due to a covered event such as a natural disaster.
• Product liability insurance protects against claims that your products caused bodily injury or property damage.
• Employee practices liability insurance covers claims from employees alleging discrimination, sexual harassment or other wrongful termination.
• Workers’ compensation insurance covers medical expenses and income replacement for employees who are injured on the job.
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Business tools can help make your life easier and make your business run more smoothly. The right tools can help you save time, automate tasks and make better decisions.

Consider the following tools in your arsenal:

• Accounting software : Track your business income and expenses, prepare financial statements and file taxes. Examples include QuickBooks and FreshBooks.
• Customer relationship management (CRM) software : This will help you manage your customer relationships, track sales and marketing data and automate tasks like customer service and follow-ups. Examples include Zoho CRM and monday.com.
• Project management software : Plan, execute and track projects. It can also be used to manage employee tasks and allocate resources. Examples include Airtable and ClickUp.
• Credit card processor : This will allow you to accept credit card payments from customers. Examples include Stripe and PayPal.
• Point of sale (POS) : A system that allows you to process customer payments. Some accounting software and CRM software have POS features built-in. Examples include Clover and Lightspeed.
• Virtual private network (VPN) : Provides a secure, private connection between your computer and the internet. This is important for businesses that handle sensitive data. Examples include NordVPN and ExpressVPN.
• Merchant services : When customers make a purchase, the money is deposited into your business account. You can also use merchant services to set up recurring billing or subscription payments. Examples include Square and Stripe.
• Email hosting : This allows you to create a professional email address with your own domain name. Examples include G Suite and Microsoft Office 365.

Many business owners spend so much money creating their products that there isn’t a marketing budget by the time they’ve launched. Alternatively, they’ve spent so much time developing the product that marketing is an afterthought.

Create a Website

Even if you’re a brick-and-mortar business, a web presence is essential. Creating a website doesn’t take long, either—you can have one done in as little as a weekend. You can make a standard informational website or an e-commerce site where you sell products online. If you sell products or services offline, include a page on your site where customers can find your locations and hours. Other pages to add include an “About Us” page, product or service pages, frequently asked questions (FAQs), a blog and contact information.

Optimize Your Site for SEO

After getting a website or e-commerce store, focus on optimizing it for search engines (SEO). This way, when a potential customer searches for specific keywords for your products, the search engine can point them to your site. SEO is a long-term strategy, so don’t expect a ton of traffic from search engines initially—even if you’re using all the right keywords.

Create Relevant Content

Provide quality digital content on your site that makes it easy for customers to find the correct answers to their questions. Content marketing ideas include videos, customer testimonials, blog posts and demos. Consider content marketing one of the most critical tasks on your daily to-do list. This is used in conjunction with posting on social media.

Get Listed in Online Directories

Customers use online directories like Yelp, Google My Business and Facebook to find local businesses. Some city halls and chambers of commerce have business directories too. Include your business in as many relevant directories as possible. You can also create listings for your business on specific directories that focus on your industry.

Develop a Social Media Strategy

Your potential customers are using social media every day—you need to be there too. Post content that’s interesting and relevant to your audience. Use social media to drive traffic back to your website where customers can learn more about what you do and buy your products or services.

You don’t necessarily need to be on every social media platform available. However, you should have a presence on Facebook and Instagram because they offer e-commerce features that allow you to sell directly from your social media accounts. Both of these platforms have free ad training to help you market your business.

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To scale your business, you need to grow your customer base and revenue. This can be done by expanding your marketing efforts, improving your product or service, collaborating with other creators or adding new products or services that complement what you already offer.

Think about ways you can automate or outsource certain tasks so you can focus on scaling the business. For example, if social media marketing is taking up too much of your time, consider using a platform such as Hootsuite to help you manage your accounts more efficiently. You can also consider outsourcing the time-consumer completely.

You can also use technology to automate certain business processes, including accounting, email marketing and lead generation. Doing this will give you more time to focus on other aspects of your business.

When scaling your business, it’s important to keep an eye on your finances and make sure you’re still profitable. If you’re not making enough money to cover your costs, you need to either reduce your expenses or find ways to increase your revenue.

Build a Team

As your business grows, you’ll need to delegate tasks and put together a team of people who can help you run the day-to-day operations. This might include hiring additional staff, contractors or freelancers.

Resources for building a team include:

• Hiring platforms: To find the right candidates, hiring platforms, such as Indeed and Glassdoor, can help you post job descriptions, screen résumés and conduct video interviews.
• Job boards: Job boards such as Craigslist and Indeed allow you to post open positions for free.
• Social media: You can also use social media platforms such as LinkedIn and Facebook to find potential employees.
• Freelance platforms: Using Upwork, Freelancer and Fiverr can help you find talented freelancers for one-time or short-term projects. You can also outsource certain tasks, such as customer service, social media marketing or bookkeeping.

You might also consider partnering with other businesses in your industry. For example, if you’re a wedding planner, you could partner with a florist, photographer, catering company or venue. This way, you can offer your customers a one-stop shop for all their wedding needs. Another example is an e-commerce store that partners with a fulfillment center. This type of partnership can help you save money on shipping and storage costs, and it can also help you get your products to your customers faster.

To find potential partnerships, search for businesses in your industry that complement what you do. For example, if you’re a web designer, you could partner with a digital marketing agency.

You can also search for businesses that serve the same target market as you but offer different products or services. For example, if you sell women’s clothing, you could partner with a jewelry store or a hair salon.

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To rank the best states to start a business in 2024, Forbes Advisor analyzed 18 key metrics across five categories to determine which states are the best and worst to start a business in. Our ranking takes into consideration factors that impact businesses and their ability to succeed, such as business costs, business climate, economy, workforce and financial accessibility in each state. Check out the full report .

Starting a small business takes time, effort and perseverance. But if you’re willing to put in the work, it can be a great way to achieve your dreams and goals. Be sure to do your research, create a solid business plan and pivot along the way. Once you’re operational, don’t forget to stay focused and organized so you can continue to grow your business.

How do I start a small business with no money?

There are several funding sources for brand-new businesses and most require a business plan to secure it. These include the SBA , private grants, angel investors, crowdfunding and venture capital.

What is the best business structure?

The best business structure for your business will depend entirely on what kind of company you form, your industry and what you want to accomplish. But any successful business structure will be one that will help your company set realistic goals and follow through on set tasks.

Do I need a business credit card?

You don’t need one, but a business credit card can be helpful for new small businesses. It allows you to start building business credit, which can help you down the road when you need to take out a loan or line of credit. Additionally, business credit cards often come with rewards and perks that can save you money on business expenses.

Do I need a special license or permit to start a small business?

The answer to this question will depend on the type of business you want to start and where you’re located. Some businesses, such as restaurants, will require a special permit or license to operate. Others, such as home daycare providers, may need to register with the state.

How much does it cost to create a business?

The cost of starting a business will vary depending on the size and type of company you want to create. For example, a home-based business will be less expensive to start than a brick-and-mortar store. Additionally, the cost of starting a business will increase if you need to rent or buy commercial space, hire employees or purchase inventory. You could potentially get started for free by dropshipping or selling digital goods.

How do I get a loan for a new business?

The best way to get a loan for a new business is to approach banks or other financial institutions and provide them with a business plan and your financial history. You can also look into government-backed loans, such as those offered by the SBA. Startups may also be able to get loans from alternative lenders, including online platforms such as Kiva.

Do I need a business degree to start a business?

No, you don’t need a business degree to start a business. However, acquiring a degree in business or a related field can provide you with the understanding and ability to run an effective company. Additionally, you may want to consider taking some business courses if you don’t have a degree to learn more about starting and running a business. You can find these online and at your local Small Business Administration office.

What are some easy businesses to start?

One of the easiest businesses to start also has the lowest overhead: selling digital goods. This can include items such as e-books, online courses, audio files or software. If you have expertise in a particular area or niche, this is a great option for you. Dropshipping is also a great option because you don’t have to keep inventory. You could also buy wholesale products or create your own. Once you create your product, you can sell it through your own website or third-party platforms such as Amazon or Etsy.

What is the most profitable type of business?

There is no one answer to this question because the most profitable type of business will vary depending on a number of factors, such as your industry, location, target market and business model. However, some businesses tend to be more profitable than others, such as luxury goods, high-end services, business-to-business companies and subscription-based businesses. If you’re not sure what type of business to start, consider your strengths and interests, as well as the needs of your target market, to help you choose a profitable business idea.

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Katherine Haan is a small business owner with nearly two decades of experience helping other business owners increase their incomes.