This study was approved by The Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine.
We organized TBL in paediatric clerkships for students who were majoring in clinical medicine from August to October 2019 at the Children’s Hospital, Zhejiang University School of Medicine.
The students were enrolled in 5-year undergraduate programmes at the Zhejiang University School of Medicine. They participated in clerkships in many specialties in their third year, including 3 weeks in paediatrics. We retrospectively reviewed the teaching methods the students experienced and their performance before and after their paediatric clerkships. The student cohort with TBL-based paediatric clerkships (TBL group) was compared with the student cohort from the prior year (control group) that used case-based discussion as the teaching method. The students’ grade point averages (GPAs) in their major courses before their paediatric clerkships were reviewed.
The paediatric clerkships for the students from the control group included 4-6 case-based discussions over 3 weeks (Table 1). The cases used in the discussions were chosen by the students themselves during their clerkships and mainly covered core paediatric topics (Table 1). In each case-based discussion, one student in one group volunteered to do the preparatory work including presenting the case to the group and organizing the discussion. The students would conduct 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. The teachers’ work was mainly to preview the students’ preparatory work (including the slides), observe the discussion, and facilitate the discussion if necessary. The groups held their discussions separately.
The paediatric clerkships for students from the TBL group contained 4 modules. The 4 modules were fixed and covered the following paediatric topics: acute gastroenteritis with fluid therapy, neonatal hyperbilirubinemia, pneumonia, and glomerulonephritis/nephritic syndrome (Table 1).
The faculty members had attended a TBL fellowship training course or a TBL workshop before the TBL started. Finally, 4 teachers participated in the TBL group. Three of those 4 teachers were the same as in the control group, including one teacher who had more than 10 years of teaching experience in paediatrics. Each TBL module was mainly conducted by one paediatric faculty member, and another faculty member would help with the readiness assurance test part.
When the paediatric clerkships started, the students would receive a brief introduction of TBL methods, including how they worked and what they should do in each component. The preparatory materials were assigned 2 days before classes, usually from certain chapters in the textbook or articles. The TBL modules were designed in the “4 Ss” framework (significant problem, same problem, specific choice, and simultaneous reporting)(8). The learning objectives were set to meet the paediatric requirements in the national examination of practicing doctor’s qualifications.
A TBL module began with a closed-book individual readiness assurance test (iRAT) containing 12 multiple-choice questions (MCQs). The iRAT had to be finished in 12 minutes. Those MCQs were based on clinical problems. Students completed the iRAT using a mini-program in the Wechat app. When teachers logged into the mini-program, they could see the iRAT results for each student and each MCQ. During the iRAT, the students did not get feedback on the right answers. Then, the students started the discussion in teams and finished the closed-book team readiness assurance test (tRAT), which included the same questions as the iRAT. The tRAT was conducted using the Immediate Feedback Assessment Technique (IF-AT) via scratch cards or voting cards. The scratch cards were made by our faculty members. The scratch cards eventually would reveal the correct answers to the students and would record the students’ confusion. The voting cards revealed the students’ initial opinions and could provoke an immediate discussion. After the tRAT with the discussion, there was a short time for a 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 were set as clinical problems. In additions, the application questions not only covered the key principles addressed in the tRAT, but they also required the application of other knowledge. After the groups demonstrated their ideas simultaneously, gallery walks started, which allowed groups to cross-examine others and leave comments. The discussion was guided by facilitators, and the groups expressed their thinking. Peer reviews were done via mobile phone after class, using the UT Austin method(8) to obtain descriptive feedback of the performance during the TBL module. That feedback would be given to the students after each TBL module. When each module ended, the teacher would assign some reading material related to the topics.
During the TBL practice, the iRAT and tRAT scores would be recorded.
At the end of the paediatric clerkships, all students would be evaluated using a closed-book theoretical exam that consisted of 100 MCQs and had a time limit. Those MCQs covered most of the topics that the national examination of practicing doctor’s qualifications required in paediatrics and not just the core topics. The ratio of each topic in the final course exam was showed in additional file 1. The students in both the control group and the TBL group took the theoretical exam with the same ratio of each topic. The MCQs that were used in the readiness assurance tests or prior theoretical exams were not repeated.
The satisfaction of the students who enrolled in the TBL group was assessed with an anonymous questionnaire when the paediatric clerkships ended. The questions in the questionnaire were answered using a five-point scale, and the response options included strongly agree, agree, neutral, disagree, and strongly disagree. Additionally, an open-ended question was included for students to provide further suggestions or comments on TBL.
The statistical analyses were conducted using SPSS version 25.0 (IBM, Armonk, New York).
Normally and nonnormally distributed continuous data were presented as the mean ±standard deviation and the median with the interquartile range (IQR), respectively.
A chi-squared test was applied to categorical variables. The Mann-Whitney test was used for nonnormally distributed data, and the t test was used for normally distributed data. Significance was considered as a p value <0.05.