Background

Internationally, medical schools have long used a variety of approaches to develop hybrid Problem based learning (PBL) curricula [1]. However, over time, a number of these hybrid PBL models have become less effective, and decreasingly aligned with the intended student-centred learning philosophy [2]. With extensive face-to-face PBL group meeting time, yet limited individual accountability for contribution to group work, student satisfaction with hybrid PBL models has decreased in recent years [2]. Introduced to Sydney Medical School (SMS) in 1997, a hybrid PBL approach has provided a long-established form of teaching within the medical curricula. However, increasing student numbers (from 142 Year 1 students in 1997 to 332 in 2016) and limited teaching resources, have rendered this model of teaching unsustainable [3]. Dissatisfaction with PBL has arisen from increasingly larger groups of students (n = 10), the time intensiveness of PBL (two 1.5 h sessions each week), insufficient peer engagement, and the variable expertise, teaching experience and enthusiasm of facilitators [3]. Our students’ declining opinion of PBL, can be attributed to lack of standardisation across the cohort, and the increasing value placed on time efficient learning strategies [3]. Earlier studies similarly reported “haphazard” PBL tutorial processes, and lack of student accountability as key contributors to students’ dissatisfaction [4,5,6]. Excellence in medical education requires adaptation of the curriculum to meet student needs [7]. Adopting a blended learning approach, with appropriate instructional strategies and efficiencies, has the potential to enhance student engagement both inside and outside of the class room [8].

An alternative to PBL that adopts a blended learning approach, is Team-based learning (TBL), which has gained recent popularity in medical education [9]. TBL allows medical educators to provide students with resource effective, authentic experience of working in teams to solve real life clinical problems [10]. Our 2014 pilot study (n = 20) of TBL [3], indicated that students favoured many aspects of the TBL process, including the pre-class work, the in-class initial tests with immediate feedback, and the problem-solving activities. Students found the advantages of TBL over PBL included better engagement in learning, deeper understanding of concepts, and a sense of responsibility towards teammates [3]. However, negative aspects of the students’ TBL experience included limited time to complete problem-solving activities, and a de-emphasis on the student-centred approach involving clinical reasoning among student groups. In 2016, based on our previous TBL pilot experience, as well as wider literature evidencing the effectiveness of TBL in health education, we sought to incorporate a sustainable and standardised TBL model across the Musculoskeletal sciences, Respiratory sciences, and Cardiovascular sciences blocks of the Year 1 medical program. Key features of TBL principles were adopted, including appropriate allocation of individuals to groups, prescribed out-of-class preparation, pre-class individual and team tests, immediate feedback, and problem-solving activities with all team work within a single session [10].

In recognition of the large variance in implementation and reporting of TBL, within the diverse range of settings, content areas and learners within health sciences education, Haidet and colleagues (2012) recently proposed a set of guidelines for standardising the way in which TBL is reported and critiqued [10]. We used these guidelines to outline the scope of our TBL program, and report our implementation. According to Haidet (2012), the “seven core design elements that underlie the TBL method” are: 1) team formation, 2) readiness assurance (RA), 3) immediate feedback, 4) sequencing of in-class problem solving, 5) the four S’s (significant problem, same problem, specific choice, and simultaneous reporting), 6) incentive structure, and 7) peer review [10].

This study sought to report on our implementation of TBL in Year 1 of a graduate entry medical program during the 2016 Musculoskeletal Sciences block, Respiratory sciences block, and Cardiovascular Sciences block. Our aim was to explore students’ perceptions of their experience during TBL, drawing some comparisons with their experience of PBL sessions.

Methods

Sampling and participants

In 2016, 169 Year 1 students completed three PBL and three TBL sessions during one of the following teaching blocks: Musculoskeletal (n = 56), Respiratory (n = 59) or Cardiovascular (n = 54).

In total, 169 Year 1 students participated in the study. Convenience sampling was used to select 18 established PBL groups (six for each teaching block). In each teaching block, the same six PBL groups were combined to form one TBL class, consisting of nine or ten teams of five or six students.

Content of the PBL and TBL sessions

The weekly learning topics for PBL and TBL during the Musculoskeletal Sciences, Respiratory sciences and Cardiovascular sciences are outlined in Table 1.

Table 1 weekly learning topics of Musculoskeletal sciences, Respiratory sciences and Cardiovascular sciences block
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Structure of problem based learning

At the time of this study, Sydney Medical School (SMP) offered a four year graduate entry medical program, with a hybrid PBL curriculum. Students were assigned to PBL groups of ten students. During Year 1 and Year 2 of the program, students attended two 1.5 h weekly PBL tutorials on university campus on separate days. The first PBL session was student led, and a facilitator was present at the second PBL session. In collaboration with their group members, students were expected to analyse a clinical problem, formulate hypothesis, and undertake self-directed learning tasks between the two PBL sessions.

Structure of team-based learning

The TBL sessions were held once per week for two hours, replacing the two PBL sessions that would normally occur.

Team formation

To reduce potential discrepancies in gender, international status, and science background of students, allocations of students into their TBL teams was carried out with a minimisation technique using a system of linear equations [11]. Students were allocated to teams consisting of either five or six students, and teams remained together for each teaching block. The Musculoskeletal class (n = 56) consisted of 10 teams of five students, and one team of six students; the Respiratory class (n = 59) consisted of seven teams of five students and four teams of six students; and the Cardiovascular (n = 54) class consisted of six teams of five students and four teams of six students.

Pre-class reading

Prior to class, students were allocated compulsory readings or/and pre-recorded lectures.

In-class schedule

The structure during class is outlined in Table 2, including the Individual Readiness Assurance Test (IRAT), Team Readiness Assurance Test (TRAT), Immediate feedback, and Clinical problem solving activities. While the principles of TBL were paramount in course design and implementation, we note that we did not include formal peer evaluation or a formal incentive structure. Rather, we assumed that students would be motivated by a sense of accountability to their teams to prepare and participate in the TBL readiness assurance process and problem-solving activities. We also note that we used open-ended responses during the problem solving activities, rather than a specific choice that is simultaneously disclosed by student teams. Although we did not have a formal appeals and dispute process, there was opportunity within the immediate feedback session for students to promote discussion and challenge answers.

Table 2 Activity schedule during Team-based learning sessions
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TBL facilitators

Nine senior academic clinicians participated as facilitators: three Rheumatologists, three Respiratory physicians, and three Cardiologists.

Data collection and analysis

Questionnaires

Student questionnaire

Two questionnaires, one regarding PBL, and one regarding TBL, were distributed to student participants following the completion of each teaching block (Musculoskeletal sciences, Respiratory sciences and Cardiovascular sciences). The questionnaires included closed items, (using five point likert-scale, with 1 being ‘strongly disagree’, and 5 being ‘strongly agree’) and open-ended questions. The questionnaire was adapted from a validated questionnaire designed by Thompson and colleagues (2009), to measure the quality of team processes in medical education [12]. Open-ended questions were also asked to elicit the best and worst features of the sessions.

Quantitative data were analysed using descriptive statistics. Thematic analysis was used to code and categorise qualitative data into themes. Once data had been coded and categorised into themes, the data within each theme were quantified in order to measure thematic prevalence [13].

Ethics approval

The University of Sydney Human Research Ethics Committee approved the study. Written consent for participation was obtained from participants to enable us to include their data from this study.

Results

Questionnaire

Student questionnaire

In total, 144/169 (85%) of participants completed a questionnaire regarding their PBL experience, and 152/169 (90%) completed a questionnaire regarding their TBL experience as follows.

Student responses to closed items regarding their experience in PBL are shown in Fig. 1. Student responses to the same closed items regarding their experience in TBL are sown in Fig. 2. Responses to two additional questions specific to TBL are shown in Fig. 3. Overwhelmingly, students preferred the smaller group size of TBL, with 85% strongly agreeing or agreeing that in TBL “the number of group members enhanced my experience of peer learning”, compared to 37% in PBL (item 9). Notably, in TBL, 93% of students strongly agreed or agreed that “all team members made an effort to participate in discussion”, compared to 46% in PBL (item 1), which was consistent with other responses (to items 2 to 5) regarding team participation. Feedback was well facilitated in TBL, with 80% of students strongly agreeing or agreeing that “I received useful and timely feedback from the tutor”, compared to 46% in PBL (item 10). Feedback was also better utilised by students in TBL, with 61% strongly agreeing or agreeing that “Team members used feedback about individual or team performance to help the team be more effective”, compared to 37% in PBL (item 6). The tutors were better able to help “focus discussions and learning” in TBL (with 82% strongly agreeing or agreeing), than in PBL (with only 38% strongly agreeing or agreeing) (item 11). Importantly, students were generally satisfied with the problem solving activities within TBL, with, 81% strongly agreeing or agreeing that “Problem solving allowed me to develop my clinical reasoning skills”, compared to 57% in PBL (item 12). In TBL, 72% of students strongly agreed or agreed that “Completion of the prescribed out-of class preparation assisted in my learning”, compared to 38% in PBL (item 8).

Fig. 1
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Student responses to closed items regarding experience in PBL (N = 144)

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Fig. 2
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Student responses to closed items regarding their experience in TBL (N = 152)

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Fig. 3
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Student responses to closed items regarding their TBL experience (N = 152)

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Additionally, as shown in Fig. 3, the majority of students (83%) strongly agreed or agreed that in TBL, the “individual and team tests at the beginning of class assisted in my learning”, and 69% strongly agreed or agreed that the “Competitiveness between groups enhanced my learning”.

Responses to open ended questions regarding students’ perceived best and most difficult features of PBL are illustrated in Tables 3 and 4 respectively. The students found positive aspects of their TBL experience to include the smaller group size, the use of readiness assurance tests, immediate feedback from senior clinicians, and time efficiency. In PBL, students reported that variable experience of tutors; limited direction; and large group size hindered their learning.

Table 3 Students’ perceptions of PBL, including best and most difficult features (N = 144)
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Table 4 Students perceptions of Team-based learning, including best and most difficult features (N = 152)
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Discussion

This study sought to explore students’ and faculty’s perceptions of PBL and TBL during Year 1 of the medical curriculum, across the Musculoskeletal sciences, Respiratory sciences and Cardiovascular sciences blocks. Results indicate that students found their experience in TBL to be overwhelmingly more positive than their experience in PBL. Students reported working in small groups of five or six students, compared to larger groups of 10 in PBL, increased participation and peer learning. They found the readiness assurance process, including the individual and team tests, motivating and engaging; and immediate feedback from a clinical expert beneficial to their learning. However, students noted that during TBL they would have liked greater opportunity to discuss their completed pathophysiology flowcharts. Although students enjoyed opportunities for clinical reasoning and discussion in PBL, they found the variable experience of tutors, limited direction, and large group size hindered their learning.

Excellence in communication and team work is essential to health care and patient safety, particularly within increasingly complex healthcare systems [14]. The structure of TBL has elements conducive to preparing students to work in teams, synthesise evidence, and communicate with each other. Students commented that the smaller groups of TBL enabled greater participation, discussion and collaboration [15, 16]. Notably, in TBL, 93% of students strongly agreed or agreed that “all team members made an effort to participate in discussion”, compared to 46% in PBL. Designated preparation for essential knowledge acquisition for TBL shifted the burden of learning content during class [17]. The majority of students (83%) strongly agreed or agreed that in TBL, the “individual and team tests at the beginning of class assisted in my learning”. Additionally, the readiness assurance test provided the facilitator with a means to immediately assess student knowledge and understanding, and address specific needs [18]. Students noted they were more likely to come to class prepared in TBL, hence the quality of team and class discussion improved. Individual student accountability was fostered by the use of the individual assessment (iRAT), while the tRAT promoted effective teamwork. Students felt a sense of friendly competitiveness among teams, which enhanced motivation to prepare. Unlike in PBL, where individual students had different preparation requirements, in TBL, all students had the same pre-class requirements, and came to class ready to engage.

Teachers are expected to be experts in their fields, with the ability to guide students to take an active learning role [19]. By following the steps in TBL, three facilitators were readily able to manage 10 small groups of students (ie, 50 to 60 students) in one room. An advantage of TBL was the increased feedback and guidance from facilitators, who were content experts. In PBL, students found the variable expertise of their facilitators, and lack of guidance, led to uncertainty, and hindered learning progress within groups. Unfortunately, feedback was often lacking in PBL teaching sessions. However, provision of immediate feedback has the ability to enhance students’ understanding of their content knowledge [18], and is crucial to knowledge acquisition, application, and retention [20, 21]. Feedback was well facilitated in TBL, with 80% of students strongly agreeing or agreeing that “I received useful and timely feedback from the tutor” compared to 46% in PBL. Although it is widely accepted that the ideal PBL tutor is a group facilitator, rather than a content expert [22], without timely feedback, errors may go uncorrected, and a students’ sense of being “lost” with new content is amplified [21]. In TBL, faculty’s expertise is utilised to design a learning experience for students that is rich in feedback [23]. Students are never left in doubt regarding their understanding of the content, with feedback being received through the readiness assurance process, and during problem-solving activities, where facilitators assist individuals and teams as required. Additionally, the provision of clinical context within medical education helps students to understand and recall content [24, 25]. Students felt that provision of clinical examples and relevant scenarios by facilitators who were clinicians during TBL led to better engagement in learning, and an increased understanding of the relevance of the basic science concepts.

In TBL, the formal testing procedure, with the sequence of the readiness assurance process ensured students had several opportunities to engage with the content and gauge their own understanding [15]. Students built on their own learning by comparing their answers to other team members, and engaging in discussion in order to come to a consensus. The TBL format provides the opportunity for students to develop critical competencies relevant to health care education: teamwork abilities and critical thinking skills. [26] In PBL, our students reported such practices were limited, and hindered by large group sizes. A previous study reporting on the effect of group size in PBL in a dental school found a correlation between small (3) to medium (6) sized groups and increased satisfaction and self-directed learning among students, compared to larger groups (9) [27]. Team learning in both PBL and TBL is promoted through implementation of the problem-solving activities [28]. However, during TBL, the small size of groups meant that all students were forced to contribute to the problem-solving activities [29], and engage with the content. Completion of tasks required productive team interaction. Students felt that in TBL, unlike in PBL, having an end product, such as the drawing of a flowchart provided a sense of satisfaction for their teams.

Notably, key features favoured by students in PBL, were the discussion oriented sessions, with broader opportunities for clinical reasoning, and the opportunity for students to discuss their own clinical experiences. Previous literature has highlighted the advantage of PBL over TBL as being the small group discussion prior to self-study [30]. Evidence suggest that group discussion, where prior knowledge is activated, may have a positive impact on learning [31]. This is an element that could potentially be incorporated to improve our TBL sessions. Within the structure of PBL, students are encouraged to plan and monitor their own learning. In PBL, students are not given pre-reading assignments. However, they are encouraged to generate their own questions and issues for further self-directed learning and group discussion, promoting lifelong learning skills [30]. As Dolmans et al. [30] suggests, by combining the positive elements of PBL with TBL, student learning may be optimised.

Study limitations

It is possible that students simply found the new method of teaching (TBL) to be novel, which may have made their responses more positive than if the study was carried out over a greater length of time. However, given the strength of students’ views, and the breadth of the study, across three blocks of teaching, we feel our conclusions and recommendations are accurate. Our findings may or may not be generalizable to other institutions and students.

Consistent with recent literature, and as noted by Michaelsen himself [32], application of TBL within the health care field is constrained by a number of pre-determined contextual factors, which reduce the ability to adhere to all classic design elements of TBL. We found allowing only one “specific choice” within the problem-solving activity phase of TBL “restricts the discussion to predetermined outcomes” [33], and instead used open-ended questions. However, the advantage of avoiding “Specific choice” within the problem-solving activity is that faculty do not need to generate the specific choice questions/answers (MCQs), which can be difficult and time consuming to write [33, 34].

Conclusions

Increasingly, the practice of medicine is both team-orientated, and inter-professional, requiring co-ordinated efforts from a number of disciplines to provide the best outcomes for patients [23]. Changes in both curricula and pedagogy are needed to prepare students for demands of the increasingly complex healthcare systems. Graduate competencies have shifted from knowledge to the ability to solve complex problems, communicate and collaborate effectively. The students found positive aspects of their TBL experience included the smaller group size, the use of readiness assurance tests, immediate feedback from senior clinicians, and time efficiency. Additionally, the application of TBL principles meant the sessions were not reliant upon a high teacher to student ratio. Although the use of TBL required an instructional approach, needing direction from the tutor, it remained student-centred, generating a range of positive outcomes. In particular, TBL resulted in better pre-class preparation, immediate feedback on progress, and smaller group size. The findings from our study strongly suggest that TBL is the students’ preferred teaching strategy. However, as noted by students during TBL, greater time needs to be devoted to discussion of the pathophysiology flow-chart. Our study results provide confidence for implementing TBL for both Year 1 and Year 2 cohorts within the Sydney Medical Program in 2017.