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.
Subjects
The students were enrolled in 5-year undergraduate programmes at Zhejiang University School of Medicine. They participated in clerkships in many specialties in their third year, including 3 weeks in paediatrics. Each round of the paediatric clerkship contained approximately 35-40 students according to their rotation plans. 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) , with whom case-based discussion was used as the teaching method. The students’ grade point averages (GPAs) in their major courses before their paediatric clerkships were reviewed.
Control Group
The paediatric clerkships for the students in the control group included 4-6 case-based discussions within 3 weeks (Table 1). The case-based discussion was a learner-centered learning. The cases used in the discussions were chosen by the students themselves during their clerkships and mainly covered core paediatric topics (Table 1). The topics were not fixed. For 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 chosen topics were usually from the cases that the students encountered during the 3-week clerkship. The students would conduct the discussion, including presenting a typical case, asking questions to other group members, and explaining the possible rationale. One teacher would be assigned to a group as an instructor. The teachers’ role 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.
TBL Group
The paediatric clerkships for students in 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 topics chosen in the TBL group depended on the teachers’ subspecialties.
The faculty members had attended a TBL fellowship training course or a TBL workshop before the TBL started. Ultimately, 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 conducted mainly by one paediatric faculty member, and another faculty member would help with the readiness assurance test portion.
The students had no knowledge of TBL before the clerkship. When the paediatric clerkships started, the students received a brief introduction to TBL methods, including how they worked and what students 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 qualifying doctors to practise medicine.
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 receive feedback on which were 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 would eventually reveal the correct answers to the students and recorded the students’ confusion. The voting cards revealed the students’ initial opinions and could prompt an immediate discussion. After the tRAT with the discussion, there was a short time for a mini-lecture conducted by the teachers. The teachers would provide 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 presented as clinical problems. In addition, the application questions not only covered the key principles addressed in the tRAT but also required the application of other knowledge. After the groups shared their ideas simultaneously, gallery walks began, 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 on 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 reading material related to the topics.
Measuring Outcomes
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. The MCQs covered most of the topics on the national examination qualifying doctors to practise medicine required in paediatrics, not just the core topics. The proportions of each topic on the final course exam are showed in the additional file 1. The students in both the control group and the TBL group took the theoretical exam with the same proportions of each topic. MCQs that were used in the readiness assurance tests or prior theoretical exams were not repeated. The percentage and accuracy of the MCQs that were covered by topics discussed in the control group and in the TBL group were reviewed and analysed.
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.
Teachers’ reflecting: The teachers were interviewed after the teaching activities with the following questions: 1) Do you think TBL was a better way of teaching, compared with case-based discussion? 2) Why do you think of that? 3) Would you prefer to use TBL over case-based discussion in your future teaching activities? Their answers were summarized.
Statistical Analysis
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-square test was applied to the 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.