Application of Team-Based Learning of Ophthalmology in China

Abstract


Introduction
Team-based learning (TBL) was rst popularized at University of Oklahoma in the 1970s, for the response to increasing class size and concern about the effectiveness of learning from lectures to large groups [1,2].It is an educational strategy that characterized by individual work, teamwork, and immediate feedback and enables student to discuss and follow structured process to enhance their active engagement [3].
With the number of medical student increase, TBL had received much attention in large group education [4].What's more, it is more competition for medical student to acquire knowledge and skills, and the ability of self-study, collaboration with each other to solve problem is highly important in this involution era [5].
However, the most popular education method for Chinese students is traditional didactic lecture (TDL).
The students more prefer to follow what teachers had talk than active participation into class discussion.
The major shortcoming of TDL is that the students receive information passively and they had little opportunity to expression opinion and exercise critical thinking.They are reluctant to initiative preview textbook and have less interesting on active thinking, thus most student cannot apply the knowledge exibly.
To improve medical teaching method within large class, here we apply TBL in ophthalmology clinical class to evaluate the way of education e ciency and student's learning ability.We launch TBL with the help of advanced electronic equipment of superstar App and aimed to assess the satisfaction and academic impacts of TBL on ophthalmology and investigate whether any other improvement of TBL would carry out.

Participants
Our study population comprised Year 3 medical students (clinical of Medicine) from Central South of China University.In the third year, students move to hospital, where they rolled into various medical subspecialties including ophthalmology; undergoing clinical clerkship during our TBL course.Eight faculty members who had been a part of the TBL teacher.In total 140 students participated in the TBL session.Human Research Ethics Committee of Central South University approved study.All methods were carried out in accordance with relevant guidelines and regulations.

Learning outcomes of the TBL
The score of IRAT and GRAT, including of score of comprehensive clinical application at the end of class and FESs were selected to provide learning outcomes in our assessment.What' s more, satisfaction questionnaire and evaluation of teaching goal also contain in our results.

Structure of team-based learning
The TBL session was 2.5 h in duration.It was held outside of the students' regular weekly schedule to preview with MOOC video and book.The students divided into 10 teams per class and distribute with evenly gender, each team consisted of approximately 14 members.Two or three teachers were randomly allocated to these group to participate the discussion section during GRAT and comprehensive clinical application task.
The process of team-based learning Pre-class reading Prior to class, all students were allocated compulsory readings and pre-recorded lectures to review.

Individual readiness assurance test (IRAT)
All students were required to complete an online quiz with superstar APP on the beginning of class.The quiz consisted of 10 multiple choice questions, with one single best answer or multi choice for each question.The questions were aligned with the pre-class reading and pre-recorded lectures.Students were provided with a 15min window to complete the quiz, and at completion, they were provided with their total score.

Group readiness assurance test (GRAT)
The same IRTA quiz was repeated by the students in their teams.The test was administered online, and students submit once answer per team, with the intent of promoting discussion to establish team consensus.

Immediate feedback and clari cation from the facilitators
The correct answers were then released and explained, giving immediate feedback on team responses in about 30min.The teacher offered clari cation, particularly where individuals or teams had trouble.

Extended lecture
Our teachers give an interest lecture with an intend of exploiting the horizon of medical student on ophthalmology learning, the content of lecture including the progress of scienti c research, operation of each disease and advanced medical technology.The time of this lecture last about 1 hour.

Clinical problem-solving activities
Students worked in their teams on problem solving activities, using knowledge consolidated through the prior steps.There was opportunity within the immediate feedback session for students to initiate discussion and challenge answers.

TBL modi cation
Each TBL class had a professional team of facilitators including: three ophthalmologists.The facilitators had been provided with prior training in TBL facilitation by either attending face-to-face training semester.
In our modi cation we provide additional profession research lecture and specialty clinical lecture with international language, which including elements such as how to prompt clinical reasoning through questioning.

Data collection
We collected data using a multiple questionnaire regarding the TBL experiences.The questionnaire was distributed to student immediately following completion of the TBL session.The questionnaires included closed items (using a ve-point Likert Scale, with 1 being 'strongly disagree', and 5 being 'strongly agree').
The interviewers used a guide that contained 7 standardized, open-ended interview questions 13 which asked about general impressions of the dissemination of TBL at the school, degree of TBL use in speci c courses, scholarship on TBL and future.A series of prompts were included to ensure that each question was explored in similar detail between interviewers.A copy of the interview guide is provided in Table 1.
All interviews were conducted over the telephone.

Data analysis
We used the descriptive statistics method to analyze our questionnaire data.Thematic analysis was used to build an understanding of the students' experience of the TBL session.A portion of the data was read by the rst author and analyzed to identify initial themes.Following negotiation of meaning with the second author, a coding framework was developed and applied to the full data set.
Differences in proportions between TBL and PL groups were tested using the c 2 test; differences in means of IRAT and GRAT scores were tested using two-sample t-test if normality and homogeneity assumptions were satis ed otherwise the non-parametric Mann-Whitney-U test was applied.A one-way analysis of variance (ANOVA) was used to compare the IRAT, GRAT, application exercise and nal examination scores among the four quartiles of students strati ed according to BOLs.All analyses were performed by SPSS software version 22.0 (SPSS Inc., Chicago, IL, USA).

Ethics approval
The IRB (Institutional Review Board) at Xiangya Hospital, Central South University, approved the study.Participation was voluntary, consent forms were signed, and anonymity was guaranteed.All methods were carried out in accordance with relevant guidelines and regulations.

Results
One hundred of forty students participated in our study TBL method (table 1).Of these, one hundred of eight questionnaires were collected at the end of our class.Mean age was 20.8 ± 0.69 years (all values expressed as mean ± SEM); 43.52% were male and 64.81% come from city.

Class Performance
The proportion of correct answers was signi cantly higher during GRAT compared to IRAT (Figure 1) and with more practice with TBL training, the performance of IRTA is getting better and better each time (Figure 1).These results con rmed that group problem solving was more effective than individual problem-solving, The average score nal exam (Figure 2) with TBL were 72.65 while the class without TBL training were 70.8.There was no signi cant difference between students with or without TBL (P =0.3434).However, the number of fail student is much higher in TDL than TBL (31vs 17) and the pass student is more in TBL than TDL (36 vs 25).The number of fair, good and excellent student are similar in TBL and TDL (43 vs 40,37vs 35 and 7 vs 5) The data showed that TBL training can match to our previous traditional method at least, and some other ability such collaboration and expression had strength during this education method.

Evaluation of TBL on teaching objectives
Students were asked to rate their TBL experience at the end of the module.We rst evaluate the teaching objectives of TBL model, and the result showed in Table 1.About 33.33% disagree that TBL can meet teaching syllabus, percentage become smaller about 25.93% disagree that they grasped the key point and di culties in TBL class.Most of our student, proximately 14.81% disagree that the teaching content extend widely than TDL.In regardless of e cient in learning knowledge with TBL training only 24.08% agree they enhanced than before.We next evaluate the discussion and Clinical problem-solving part on TBL, we get a higher percentage of agree their role in learning knowledge, what's more student about 94.45% are willing to spend more time on preview.This is an important ability of self-learning and increase their competitiveness in future study.

Evaluate learning ability and interest in ophthalmology
We next investigate the effect on learning ability and study interest, we focus on oral expression, independent thinking and time management, the percentage of disagree are 20.37%,18.52% and 25.93% (Table 2), there seem no signi cant difference between these abilities.Some other learning ability, such as self-learning and collaborate are thought to be improve at the percentage of 77.78% and 64.81%.We continue to assess the interest in ophthalmology and time in spent on including expand theme's scope of knowledge, the result showed that students agree or partially agree of this effect of TBL at 64.81%,69.44%and 92.59%.

Evaluate team working ability and clinical ability
The aim of TBL was to increase the ability of collaborate, thus we wonder whether teamwork was somewhat enhanced, and we also collect data of their clinical competence after our TBL class.We clarify our issue into following part, such as participation of each person, different opinions existence and acceptance.The data showed on

Evaluate satisfaction of TBL
At last, we focus evaluation of satisfaction of TBL, students believed TBL helped to master their present knowledge, provided them with more opportunity of expression themselves and had a positive impact on their learning attitudes.In table5, however less student give satisfaction during these three questions, In Figure1 showed an increase score up to 80 and slightly down at 80-100 point when ask satisfaction with TBL.The score tendency of active atmosphere and discussion opportunity in TBL class is consistent with the satisfaction quiz (Fig4-6).

Discussion
Over the past 30 years, educators in college campuses have increasingly employed an group teaching method called TBL [6].It had been stated that collaborative can play a signi cant role in mitigating many of the challenges faced by intensi ed competition world.We embarked on a study of TBL to determine whether this instructional strategy had value for use in medical education.This study sought to explore the collaborate effectiveness and medical students' perceptions of their learning experience during TBL session on the curriculum of ophthalmology.TBL had a positive impact on acquiring knowledge and utilize it, we choose to apply TBL on ophthalmology because of small curriculum and independence, this is very applicable to analyze the role of TBL in medical education in China.By working together, students' GRAT scores were signi cantly higher than their IRAT scores.Students showed more interest and spent more time on ophthalmology.Additionally, the more than half of students were satis ed with our TBL approach.
Before our class, we use MOCC and guidebooks to publish tasks.TBL method was unacceptable at rst because of heavy task, they didn't have enough time to preview all curriculum, after several TBL training, student tend to accept it and more will to spent time on preview.
During our class, we use Superstar APP for test during our TBL class, it can show the learning results immediately, so that students' wrong knowledge points are displayed in the form of pie chart (Figure 3), better than the previous scratch card.It is very convenient for teachers to understand students' knowledge.
It has been generally accepted that with group learning methods such as TBL, the groups should outperform the individuals [7].The analysis of pre-class tests (Figure1) indicated that the average group scores were higher than the average individual scores.This result suggested that the group-based learning increasing problem solving than individuals.During the group discussion, students could communication and debate to resolving problem.Our education seems more effective compared to that acquired from listening to teachers based on response of questionnaire.
However, we also found that the section of group discussion was not erce, the students are fear to communicate with each other even they had idea, this may on account of the spoon-feed education pattern, and Traditional Didactic Lecture is the most universal education model in china since primary school, the students are afraid of expression themselves, they are more inclined to listen than deliver their opinion.
In our survey, we collect feedback at the beginning of our TBL, most of the student are not acceptable for this model.57.8% of them are more willing to come back to TDL.They complain with little time to preview because of heavy task of their study work.In the program of medical student in china, student enter medical undergraduate program after high school, this makes our students need to learn more basic knowledge in their MD program, and virtually increased the learning task of medical students.
Moreover, in our study we found TBL is superior to the lecture-based learning only when students have reached a comparably understand of ophthalmology theories; otherwise, it will be di cult for students to answer quiz and engage in effective discussion. he data show that about 47% of them have trouble of online quiz on the begin of class, but at the end of several TBL class, only 4.63% of the student agree of the di culty of IRAT (Table 1).We thought this would be improvement of preview and learning ability though several times training.In addition, 35% of them thought the number of each group is overloaded, this affects the individual discussion in GRAT and Clinical problem-solving activities.There was a study demonstrated that the optimal size of a TBL team is considered to be ve to seven members [8].In our experience, 14 membrane is too much for group discussion and we thought the number should control under 7, since each of the member had opportunity to discussing.
Previous studies [9] have shown that one of the major bene ts of TBL was to improve the learning outcomes.We evaluated the effect of TBL on students' performance by nal exam scores (FES), and analysis the mechanisms by interpretation of questionnaire results (Table1-4).Interesting, our results showed that the FESs of TBL teaching had not signi cant been improved.But the fail rate has decreased markedly from 31 to 17, and this suggest the number of students mastering knowledge has increased.
The questionnaire shows that enhancement of personal knowledge through interaction with team members and the time spent on understanding curriculum was improved, thus we thought TBL is an effective education to gain knowledge and more favor of improving teamwork ability, independent learning ability and knowledge application ability.
Interesting, our students are more willing to be neutral when there was a chose of neutral in each quiz, but they are likely to be partially agree if options had no neutral.This suggests that most of our student aren't sure about the effect of TBL on themselves, neither about their future planning.They indeed do not know what is most suitable for them.In general, the reason of this phenomenon may attribute to long time of spoon-feed education and students are reluctant to express their ideas too radicalness.We need to improve our discussion step since highest proportion of disagreement on team discussion facility understanding knowledge.At this point, TBL will be a kind of quality cultivation, learning from excellent team members.
In conclusion, we are using questionnaire to gain insight into the utilization of TBL in medical education.With the use of TBL increased, while it is not popularized in China undergraduate education.We are on the way to grope Chinese-adapted TBL model.Several factors at the faculty, student, course and administrative ⁄ curricular levels were associated with those changes.Those who desire to implement   The nal exam score of TDL and TBL education.ClassI using TDL and ClassII using TBL.Your satisfaction with TBL teaching evaluation Evaluate the active atmosphere in TBL class Discussions in TBL increase interaction between classmates or teachers

Figure 1 The
Figure 1

Figure 3 an
Figure 3

Figure 4 Page
Figure 4

Table 3 ,
4. Most of student choose neutral attitude on each question.For the highest agree percentage, most classmate are thought the TBL help to improve teamwork at level of the acceptance of different views, on the other hand only 24.07%student thought they were concentrating when they debate, this means we should allocate more teacher to help each group to engage in discussion section.

Table 1
Questionnaire results about the teaching objectives among students in the TBL