This study was approved by The Ethics Committee of Children’s Hospital Zhejiang University School of Medicine.
We organized TBL in pediatric clerkship for students who were major in clinical medicine from August to October in 2019 at Children’s Hospital Zhejiang University School of Medicine.
Subjects
The students were from Zhejiang University School of Medicine who had 5-year undergraduate programs. They had clerkship in many specialties in the third year, including 3 weeks in pediatrics. We retrospectively reviewed the students’ teaching methods and their performance before and after a pediatric clerkship. The student cohort with TBL-planted pediatric clerkship (TBL group) was compared with the student cohort from the prior year (Control group) which was using case-based discussion as the teaching method. The students’ grade point averages (GPA) of major courses before pediatric clerkship were reviewed.
Control Group
The pediatric clerkship for students from the control group contained 4-6 case-based discussions in 3 weeks (Table 1). The cases used in the discussion were chosen by students themselves during the clerkship and mainly covered core pediatric topics (e.g. pneumonia, acute gastroenteritis). In each case-based discussion, one student in one group was voluntary to do the preparing work including presenting the case to the group and organizing the discussion. The students would domain the discussion, including presenting a typical case, asking questions to other group members, and explaining the possible rational. One teacher would be assigned to a group as an instructor. Teachers’ work was mainly about previewing the student’s preparing work (including the slides), observing the discussion, and facilitating if necessary. The group held their discussion separately.
TBL Group
The pediatric clerkship for students from the TBL group contained 4 modules. The 4 modules were fixed which covered those pediatric topics: acute gastroenteritis with fluid therapy, neonatal hyperbilirubinemia, pneumonia, glomerulonephritis/nephritic syndrome (Table 1).
The faculties had attended a TBL fellowship training or a TBL workshop before TBL beginning. Finally, 4 teachers participated in the TBL group in total. 3 of those 4 teachers were the same as in control group, including one teacher who had more than 10 years of teaching experience in pediatrics. Each TBL module was mainly conducted by one pediatric faculty member, and another faculty would help with the readiness assurance test part.
When pediatric clerkship started, the students would receive a brief introduction of TBL methods, including how this worked and what they should do in each component. The preparing materials were assigned 2 days before classes, usually from certain chapters in the textbook or articles. TBL modules were designed in the “4 Ss” framework (Significant problem, Same problem, Specific choice, Simultaneous reporting). Learning objectives were set to meet the pediatric requirements in the national examination of practicing doctor’s qualifications.
A TBL module began with an individual readiness assurance test (iRAT) containing 12 multiple-choice questions (MCQs) in closed-book. IRAT was going to be finished in 12 minutes. Those MCQs were based on clinical problems. Students were doing iRAT using a mini-program in the App of Wechat. When teachers logged in the mini program, they could see the results of iRAT for each student or each MCQ. During iRAT, the students didn’t get feedback on knowing the right answers. Then the students started the discussion in teams and finished team readiness assurance test (tRAT) which were the same questions as iRAT also in closed-book. TRAT was conducted using Immediate Feedback Assessment Technique (IF-AT) (such as scratch cards) or voting cards. Scratch cards were made by our faculties. Scratch cards eventually would reveal the correct answers to the students and also would record the students’ confusion. Voting cards revealed the students’ opinions for the first time and could provoke the discussion immediately. After tRAT with discussion, there was a short time for the mini-lecture conducted by teachers. The teachers would give feedback and clarification to ensure that the key principles were understood by all the students. The application began with another clinical case. The questions set as clinical problems. And questions in application were not only covered the key principles discussed in tRAT but also need applying other knowledge. After the groups demonstrated their ideas simultaneously, gallery walks started which allowed groups to cross-exam others, leaving their comments. The discussion was guided by facilitators; the groups expressed their thinking. Peer reviews were done by mobile phone after class, including using the Fink method(8) to reassess members’ contribution to their team’s success and using the UT Austin method(8) to obtain descriptive feedback of the performance during TBL module. That feedback would give to the students after each TBL module. When each module ended, the teacher would assign some reading material related to the topics.
Outcome Measure
During the TBL practicing, the iRAT and tRAT scores would be recorded.
At the end of the pediatric clerkship, all students would be evaluated by a theoretical exam which consisted of 100 MCQs in closed-book within a certain time. Those MCQs should cover most of the topics that the national examination of practicing doctor’s qualifications required in pediatrics, not just core topics. Repeating MCQs as used in readiness assurance test wasn’t allowed.
The satisfaction of students who enrolled in the TBL group was assessed with an anonymous questionnaire when pediatric clerkship ended. The questionnaire was answered by a five-point scale: strongly agree, agree, neutral, disagree, strongly disagree, and an open-ended question for a further suggestion about TBL.
Statistical Analysis
Statistical analyses were conducted by SPSS version 25.0(IBM, Armonk, New York).
Continuous data were presented as mean ±standard deviation which showed with normal distribution or median with interquartile range (IQR) which showed with non-normal distribution.
A Chi-square test was used for categorical variables. Mann-Whitney test or Kruskal-Wallis test were used for non-normal distribution data and t test was used for normal distribution data. Significance was considered as a P value <0.05.