Validation of TBL-PBL Teaching Model in the Organ System-based Medical Curriculum

doi:10.21203/rs.3.rs-2469608/v1

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Validation of TBL-PBL Teaching Model in the Organ System-based Medical Curriculum

https://doi.org/10.21203/rs.3.rs-2469608/v1

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BACKGROUND

The organ system-based medical curriculum is crucial for students in the MD-PhD program of Xiangya School of Medicine at Central South University in China. The combination of Team Based Learning (TBL) and Problem Based Learning (PBL) forms a new case-based teaching model so that students can cooperatively participate in case discussions using multi-disciplinary knowledge. The aim of this study is to utilize TBL-PBL teaching model in the organ system-based medical curriculum, and assess the feedback on teaching arrangement, effectiveness and the academic performance of students.

METHODS

This is a single institution, two-year study that includes two cohorts of students who participated in two training paradigms, traditional teaching model and TBL-PBL teaching modal. The MD-PhD students enrolled in 2016 (n=100) were selected for traditional teaching model, students enrolled in 2017 (n=100) were selected for TBL-PBL teaching model, in which the learning contents were remodeled and integrated with simulated cases, taught by an interprofessional team. After completing the curriculmn, all students were surveyed on their feedbacks about group teaching arrangement and teaching effectiveness. Academic performance were also assesses by post-session quizzes, periodical tests and the final exams.

RESULTS

The survey results revealed that in the TBL-PBL teaching group, the percentage of students who thought that the teaching objectives were challenging reached 94%. Meanwhile, for the traditional teaching group, the percentage of students who thought likewise were 84%. The percentage of students in the TBL-PBL group who thought that the innovative teaching mode rendered helpful in consolidating basic medical knowledge structure (89% vs. 78%), promoted student overall thinking skills (94% vs. 84%), communication skills(93% vs. 82%), teamwork skills (95% vs. 82%) and professional abilities (89% vs. 84%) outweighed the traditional teaching group to a significant degree. The academic performance in the TBL-PBL group was improved evidenced by higher class scores(85.52 vs. 80.34), excellence rate (51% vs. 49%) and qualification rate (100% vs. 92%).

CONCLUSION

The TBL-PBL teaching model improved academic performance, yielded higher student satisfaction and engagement. This innovative teaching model can be used as an alternative to traditional model for medical courses.

Team Based Learning

Problem Based Learning

Medical Education

MD-PhD Program

Organ system-based medical curriculum

With the development of economy and technology, globalization is becoming increasingly important in medical education, as medical knowledge and scientific research have pushed through the boundaries of continental borders. In July 9th of 1999, the Institute for International Medical Education (IIME) established the “Global Minimum Essential Requirements in Medical Education (GMER)”(Schwarz, Wojtczak, & Stern, 2007) and specifically defined the required core skills for medicine-related jobs all over the world. In agreement with international medical education, Central South University in China set up an organ system-based medical curriculum for MD-PhD program medical students in 2014, aiming at improving the quality of medical education (Huang et al., 2014; Patel, Yoskowitz, & Arocha, 2009; Zhu, Sun, & Guan, 2020). During this curriculum reform we underwent teaching content integration, teaching mode reformation and teaching evaluation, also introducing new case discussion methods(Thistlethwaite et al., 2012), which led to satisfying results(Ren, Yin, Wang, & Roy Schwarz, 2008). However, providing the complexity, breadth and depth of the knowledge in the organ system-based curriculum, as well as its correlation with almost all organs and systems in the body, it can be challenging for teachers to help the students to fully understand the knowledge and, more importantly, to utilize the knowledge to solve real problems in more clinical scenarios, by traditional teaching methods such as lectures.

The “Team Based Learning” (TBL) teaching method advocates students to gather into groups, completing the assignment together through self-learning and group discussions under the guidance of teachers. This teaching mode puts emphasis on teamwork, fills up the loophole of incomplete understand of knowledge, and increase active learning for students instead of passive listening (Burgess et al., 2017; Burgess et al., 2019). The “Problem Based Learning” (PBL) teaching method is to stimulate students’ learning enthusiasm by presenting simulated cases and questions, driving them to answer the questions through actively collecting relevant information and discussion (Elangovan et al., 2016; Zhao et al., 2020). Both TBL and PBL models are student centered and encourage active learning, which are helpful in improving the overall understanding and application of medical knowledge.

The combination of TBL and PBL (Burgess, Roberts, Ayton, & Mellis, 2018) forms a novel case-based teaching method by which students can cooperatively participate in case discussions using multi-disciplinary knowledge. Well prepared simulated cases and questions are assigned to students as teaching materials by teachers. During self information collection, group discussion and presentations, basic knowledge is acquired. A deeper level of understanding and the application of acquired knowledge is reinforced during in-person classroom sessions by team-based discussions under the guidance of an interprofessional teaching team who are well versed in the assigned teaching materials. At the same time, this novel model trains the expressive abilities, raises competitive awareness and guides students to learn comprehensively, objectively and systematically, expanding the breadth and depth of learning.

Therefore, in response to the necessity of improving the teaching equality in the organ system-based medical curriculum, we compared the TBL-PBL teaching model with the traditional teaching model in the organ system-based curriculum among MD-PhD program medical students. The aim of this study is to (1) explore the feasibility of implementing the TBL-PBL model in medical courses; (2) analyze the feedbacks about group teaching arrangement and teaching effectiveness; and (3) evaluate the effectiveness of TBL-PBL model at improving academic performance.

Study design

1. The teaching team

The interprofessional teaching team consisted of ten teachers specialized in Physiology, Pathophysiology, Histology & Embryology along with two attending physicians specialized in Hematology and Intense Care Unit.

2. Teaching content arrangements

We divided the teaching content during the semester into three units: (1) Blood; (2) Water-Electrolyte Balance/Acid-Base Balance Disorder; and (3) Energy Metabolism & Temperature Regulation. According to the teaching arrangements, three simulated cases were deliberately chosen for each unit including the case of “The Unfortunate Camper”, the case of “It Could Have Been Worse” and the case of” Is Stone To Blame?”, and ten to fifteen questions were extracted, including questions such as “If you were the physician, how would you explain the patient’s condition to the family members?”. Four in-person classroom TBL-PBL sessions were set up for each unit. The first two sessions were put at the start of each unit, while the other two were put at the end.

3. Teaching process (Figure 1)

(1) During the first TBL-PBL class, the subjects were split into 4 groups and studied the simulated cases and questions mainly by in-class self-learning and team discussions. After class, they were guided to put forward any unresolved questions pertaining to the simulated cases, filling in the case study information chart at the same time. The questions filtered by teachers were uploaded to the Tronclass online education system, along with the case study information charts. The teacher reminds the groups that they will be required to give a full presentation at the next TBL-PBL session.

(2) In between the TBL-PBL sessions, didactic teaching was arranged to explain the content of the unit in detail.

(3) The second TBL-PBL class focused mainly on “PBL”. Professors and clinicians joined in with the groups, and held debates to discuss the case and the remaining questions. The teachers made careful observations and also explained certain knowledge points according to student performance.

(4) In all the TBL-PBL sessions, students were asked to wear a nametag to be easily recognized by the teachers. The teachers were required to observe closely and keep detailed records of student performance. Based on these records, students were graded and given feedback so that they can acknowledge their performances and correct their shortcomings, improving comprehensive abilities.

Evaluation Indicators

1. General evaluation score

(1) TBL-PBL lesson evaluation scores (15%) ---based on participation, group communication, reference ability, critical thinking and teamwork skills, 20 points in total.

(2) Tronclass post-session quiz scores (10%) --- contains 20 single or multiple-choice questions to test the learning outcomes, 3 quizzes in total.

(3) Tronclass periodical test scores (15%) --- contains 50 single or multiple-choice questions

(4) Final exam results (60%) ---consists of basic theoretical questions

2. Student evaluation

Students upload feedback onto the Tronclass teaching program for the teachers to take into consideration and improve teaching

Statistical Analysis

The measurement data were expressed as (x±s), and t-test was used for comparison between the two groups. The count data were presented as percentages (%), and the between-group comparison was compared by χ2 contingency tables. P<0.05 was considered statistically significant.

General Information

A total of 100 students per group were included in the present study. Their genders strike a balance of male: female = 6:4 and their ages ranged from 20 to 23. Since there was no significant difference in gender, age or other general characteristics between the two groups, the data was comparable. Furthermore, only students from the TBL-PBL group were required to fill out an evaluation survey regarding their taken course, therefore no comparison was made in this domain.

Group Teaching Arrangement Survey Results

After class, students from the TBL-PBL group and the control group were asked to complete the same anonymous Tronclass questionnaire to briefly describe their experiences and perceptions. It questioned upon whether the teaching arrangements were reasonable, whether the goal was clear and whether the contents taught were challenging. In the TBL-PBL group, the percentage of students who thought that the teaching objectives were clear, reasonable and challenging reached 92%, 91% and 94%, respectively. Meanwhile, for the control group, the percentage of students who thought likewise reached 90%, 92% and 84%, respectively (Table 1). These results demonstrate that students in both groups agree that the teaching goals were clear (P > 0.05) and that the teaching arrangements were reasonable and logical (P > 0.05). However, it is notable that there are more students in the TBL-PBL group who thought that the teaching contents were challenging in comparison with the traditional group.

Table 1

Evaluation of the teaching arrangements
Items	TBL + PBL group (percentages)		Traditional group (percentages)		P value
Items	YES	UNCERTAIN/NO	YES	UNCERTAIN/NO
Clear teaching goals	92(92%)	8(8%)	90(90%)	10(10%)	0.6212
Reasonable arrangements	91(91%)	9(9%)	92(92%)	8(8%)	0.6168
Challenging content	94(94%)	6(6%)	84(84%)	16(16%)	0.0238

Group Teaching Effect Survey Results

The questionnaire also consisted questions about whether the course can help to consolidate basic medical knowledge structure, inspire early clinical thinking and critical thinking, improve medical professionalism, enhance communication skills or cultivate team spirit. As shown in Table 2, 89% of students from TBL-PBL group agree that the TBL + PBL teaching method rendered helpful in consolidating basic medical knowledge structure, 94% of students thought that this was effective in cultivating their early clinical thinking skills and critical thinking skills, 89% of students agreed that this course promoted professionalism, 93% of students acknowledged that their communication skills were practiced and matured, an average of 95% of students noted that their teamwork abilities were promoted. In the traditional group, those who thought likewise accounted for 78%, 84%, 89%, 82% and 82%, respectively.These specific results reveal that the number of students in the experimental group who thought that the novel teaching mode promoted student overall thinking skills, communication skills, teamwork skills, professional abilities outweighed the control group to a significant degree (P < 0.05).

Table 2

Evaluation of the teaching effects
Items	TBL-PBL group (percentages)		Traditional group (percentages)		P value
Items	YES	UNCERTAIN/NO	YES	UNCERTAIN/NO
Consolidates basic medical knowlege	89(89%)	11(11%)	78(78%)	22(22%)	0.0361
Cultivates early clinical thinking and critical thinking	94(94%)	6(6%)	84(84%)	16(16%)	0.0238
Improves professional skills	89(89%)	11(11%)	84(84%)	16(16%)	0.0460
Improves communicating skills	93(93%)	7(7%)	82(84%)	18(16%)	0.0180
Improves teamwork ability	95(95%)	5(5%)	82(84%)	18(16%)	0.0040

General Academic Performance

Quizzes were conducted to evaluate what the students gained from the organ system-based curriculum, which comprised of post-session quizzes (including class evaluation), periodical tests and the final exam. These scores were combined and analyzed to make up their final evaluation marks. For their final evaluation, the qualification line was 60%, while a grade of 85% and above was considered excellent.

We compared the discussion class scores of the students in both the traditional group and the TBL-PBL group (Table 3), only to discover that the former group obtained an average score of 80.34, while the latter group reached an average score of 85.52. This proves that the discussion class scores of the TBL-PBL group was noticeably higher than that of the traditional group(P < 0.05).

Table 3

General academic performance evaluation
Group	Total count	Average score	Standard deviation	P value
TBL-PBL group	100	85.52	6.23	0.000
Traditional group	100	80.34	5.82	0.000

Comparing the general scores of the students in the traditional group and the TBL-PBL group (Table 4), it is obvious that there are 49 out of 100 students in the former group who reached the line of excellence, while 8 students weren’t qualified. However, there are 51 students who reached the line of excellence in the TBL-PBL group, and all students qualified for their tests. These results show that the excellence rate in the TBL-PBL group was slightly higher than the traditional group, and the qualification rate improved significantly.

Table 4

Between-group general academic performance comparison
Group	Total	Excellent	Excellence rate	Qualified	Qualification rate
TBL-PBL group	100	51	51%	100	100%
Traditional Group	100	49	49%	92	92%

How to adequately integrate the organ system-based curriculum of clinical medicine is a prime topic in current Chinese medical education. The organ system-based medical curriculum an important curriculum of clinical medicine pertaining to the MD-PhD programs students of Central South University. According to the concept of "Outcome Based Education" (OBE)(Rosenberg, 2018), teaching goals in the curriculum aimed to elevate student knowledge, ability and quality. And then, the following teaching design was carried out according to the principle of "reverse design and positive implementation”.

With the patient-centered concept, three simulated cases were carefully selected and the teaching content was reconstructed, while the knowledge of Physiology, Pathophysiology and Histology & Embryology were engaged with the cases and questions. At the same time, we introduced clinicians into the teaching of basic courses at an early stage, which laid a solid foundation for students’ knowledge of clinical medicine. It improved their ability to solve complex problems, cultivated their preliminary clinical thinking skills, and deepened their understandings of professional ethics, work competence and the humanistic care spirit. This curriculum strives to break the disciplinary boundaries of traditional medical education and make full use of various teaching resources. According to the student-filled evaluation questionnaire regarding the teaching plan, 92% of the students believed that the teaching goal was clear; 91% of the students agreed the teaching arrangement was reasonable; 94% of the students thought that the teaching content was challenging, and those of the experimental group was higher than that of the control group. The statistics above show that the TBL-PBL teaching mode is not only theoretically advanced, but also reveals a broader vision, a deeper impression and more distinctive content. It is more easily understood and can be better accepted by students, enhancing academic challenges in an encouraging way and expanding the width and depth of education, improving overall medical teaching quality.

The teaching process of this system combined the TBL-PBL teaching model with the traditional teaching model, changing the conservative teaching method as a whole, and focuses on stimulating students’ innovative ideas and teamwork awareness. By proposing the "problem-oriented, student-centered, group-discussed and teacher-guided" teaching method, it deepens their mastery and understanding of the organ system and promotes their professionalism. The results show that this teaching model has three obvious advantages over the traditional teaching model:

1. It is essential in improving students’ learning efficiency and consolidates their basic medical knowledge. The theoretical knowledge of the organ system-based curriculum is relatively abstract and the conventional way of teaching is too simplistic, which decreases student interest and therefore results in low learning efficiency. Research shows that the top-to-bottom level of the "Learning Pyramid" is to listen, read, audio-visual, demonstrate, discuss, practice and teach others. The lower the level, the more efficient the learning (Masters, 2020). This system adequately adopts the teaching mode of "TBL + PBL" and combines it with traditional teaching. Firstly, it uses real clinical cases, adopting the TBL teaching method, and allows students to raise questions as a team. Students then experience traditional didactic learning and post-session discussions regarding the questions, and finally uses the PBL teaching method to solve the problems. These diverse teaching methods accumulates the amount of time students put into discussion, practice or teaching others, granting then with a strong sense of achievement, while also promoting in-class participation and improving learning effectiveness. In addition, students can also discover and fill their own knowledge gaps along the way, therefore securing their theoretical knowledge structure. The evaluation questionnaire showed that most of the TBL-PBL group students (89%) thought that this teaching mode was helpful in basic medicine absorption, and this student percentage outweighed the control group to a great degree. From the discussion class scores and the general evaluation, the TBL-PBL group scored relatively higher than the control group, which proves that the TBL-PBL teaching method can effectively enhance the learning efficiency of students and reinforce basic medical knowledge.

2. It is helpful in cultivating student innovation and enhancing early clinical thinking and critical thinking, promoting student career competency. The traditional lecture teaching model were consisted of large classes and mainly lead by teachers. Students passively accept knowledge rather than actively searching for knowledge, resulting in the separation of basic medical knowledge and clinical practice, which affects their ability to solve problems, also interrupting their clinical thinking and critical thinking. The TBL-PBL teaching mode is obtained in small groups and is led by clinical cases and problems. It enables students to become the center of the whole teaching process and actively discover, discuss and solve problems. They were asked to collect, sort out, analyze and refine data around their own discoveries, and solve problems through group collaboration and discussion, so as to practice their innovation abilities and their self-directed learning abilities. In the TBL + PBL teaching method, the teacher mainly takes the place of a bystander, occasionally asking questions and helping with the difficulties and mistakes in discussion, guiding students to dig deep and analyze theoretical knowledge to practice their critical thinking. This method also uses the dual-teacher classroom model consisting of a teacher specialized in basic medicine and a clinician to create a virtual scenario by role-playing patients or doctors, which helps students digest and use the medical knowledge learned and promote clinical thinking. It brings out questions such as: “If you were the doctor, how would you communicate with the patient or his/her family?” or “If you were the doctor, how can you explain this condition to family members?”, the purpose of which is to encourage students to think and solve problems like a real doctor, deepening their understandings of social responsibilities, professional ethics, work competence and humanistic care(Song & Tang, 2017). In this study, questionnaire results also reveal that more than 90% students believe that the TBL-PBL teaching mode is useful in cultivating early clinical thinking and critical thinking (94%) and improving medical professionalism (89%). These numbers are obviously higher than that of the control group, which is in line with our expected goal.

3. It increases student communication and raises teamwork awareness. GMER requires medical graduates to have the ability to mutually create a learning environment through communication for patients, relatives, colleagues or other members of the health care team. The application of "TBL-PBL" comprehensive teaching model can better promote person-to-person communications. Each person has his own limitations; therefore it is difficult to thoroughly analyze and solve problems by thinking alone. Students can find their own blind spots and acquire knowledge by communicating with each other, clarifying their own opinions, learning from other people’s views, considering problems from an overall perspective and discovering a better way to solve the problem. When learning as a team it created a suitable atmosphere that promoted cooperation among students, which in turn affected learning outcome. The viewpoints above were proved in the surveys, which showed that nearly 90% of the students thought that this teaching mode rendered helpful in improving their communication skills (93%) and cultivated their teamwork ability (95%), which outweighed the control group to a significant degree.

In the practice of this study, it was found that in order to successfully carry out TBL-PBL comprehensive teaching in the organ system-based medical curriculum, there were two key problems to be grasped. The first was to select and prepare high-quality simulated cases. In order to carry out high-quality TBL-PBL sessions, the cases should be realistic and representative, the case-based problems designed must be well-targeted and should be able to blend into theoretical knowledge. Moreover, teachers were required to have solid basic theoretical knowledge and rich clinical experience. They should constantly expand their own knowledge, prepare sufficient teaching resources, and be prepared for challenges from the students. At the same time, teachers must have the ability to control the pace of the whole class and guide students to carry out discussions orderly.

In conclusion, the novel TBL-PBL teaching model improved students’ academic performance and yielded higher student satisfaction and engagement when compared to traditional teaching model in the organ system-based medical curriculum. This innovative teaching method stimulates student’s motivation and enhance cooperation. It also reasonably increases academic challenges, elevates the difficulty of the course, expands the depth of the course, and effectively improves the teaching quality of medical undergraduate students. We hope to make them meet the standards of GMER and use as an alternative to traditional model in more medical courses.

Ethics Approval and Consent to Participate

We confirm that all experimental protocols were approved by the Central South University Ethics Committee. Informed consent to participate in the study was approved by the review board of Central South University Ethics Committee and obtained from all participants. All methods were carried out in accordance with relevant guidelines and regulations.

Availability of Data and Materials

All data generated or analysed during this study are included in this published article.

Author Contributions

YZ and LL: questionnaire survey, data sorting, statistical analysis, and paper writing. HW, QL, ST, BJ and ZX: questionnaire survey, data sorting, statistical analysis. HZ, YL and WX: research guidance, paper conception, and revision. All authors contributed to the article and approved the submitted version.

Consent for Publication

Not applicable.

Competing Interest

The authors declare no competing interest.

Funding

The research is funded by Educational Reform Funds of Central South University (2020jy141), Educational Reform Funds of Central South University (2021jy121), Educational Reform Funds of Central South University (2021KCSZ076).

Acknowledgement

Not applicable.

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No competing interests reported.

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Validation of TBL-PBL Teaching Model in the Organ System-based Medical Curriculum

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Abstract

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Introduction

Methods

Results

General Information

Group Teaching Arrangement Survey Results

Group Teaching Effect Survey Results

General Academic Performance

Discussion

Conclusion

Declarations

References

Additional Declarations

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