Team-based Learning (TBL) in the Health Professions

by Mallory Pullman, PGY1 Pharmacy Practice Resident, The University of Mississippi Medical Center 

Today, to meet the current healthcare needs of society, health professions students must be able to learn vast amounts of information and have a deep understanding of difficult concepts. In addition to having a comprehensive knowledge base, health professions students must be able to apply this knowledge to varying clinical scenarios.  Further, they must be able to work both independently and in collaboration with others. It is therefore necessary that teaching approaches in health professions education be tailored to these needs, preparing students for their careers. 

One method of learning that is starting to gain traction within health professions education is team-based learning (TBL). TBL is an instructional method that emphasizes self-preparation outside of class followed by the application of the knowledge learned in class. In TBL, courses are typically separated into modules or units and students are assigned to small groups. Before class, students are given materials to review, which they must learn independently. Assigning materials to review prior to class ensures students are responsible for their own understanding and gives students the opportunity to learn the material in a way that is most effective for them.

Then, at the start of each class, students are given an assessment to analyze how well they have learned the material. The assessment is termed an individual Readiness Assurance Test (IRAT).  Students first complete the test as an individual and, then, as a team – an assessment called the group Readiness Assurance Test (GRAT). Both the individual and group scores contribute to students’ grades. After the students complete the team test, they have the opportunity to discuss the material with the instructor and appeal answers they got incorrect. The discussion and appeal process enhances students’ understanding by requiring students to defend their answers. Students also learn by listening to the rationales provided by other teams, providing students with diverse perspectives. To conclude the assessment portion of each class, the instructor may present a brief lecture and lead a discussion on concepts students appear to be struggling with most. To further reinforce students’ learning, the remainder of each class is focused on completing application exercises.¹ 

Before deciding to implement TBL, it is crucial to examine how effective the learning method is, especially in health professions education. Constructivist learning theory, whereby the student “constructs” his/her own knowledge, provides the theoretical basis for TBL. TBL places the responsibility of learning on students by requiring them to be prepared for assessments at the start of each class and be ready to use their new knowledge to solve relevant problems.²  Several studies have shown TBL improves learning. One study assessed the impact of TBL on academic performance during comprehensive course examinations for second-year medical students.³ In a 2-year analysis of 178 second-year medical students, analyzing scores on 28 comprehensive course examinations, the investigators found that grades increased by a mean of 5.9% after TBL implementation, with lower-achieving students reaping a greater benefit.³ The authors concluded that the application exercises, allowing teams to use their aggregated knowledge to solve challenges, and the interaction with peers and faculty, likely contributed to the positive impact on students’ learning.

Similarly, a study conducted by Zgheib and colleagues examined the effect of TBL on learning in a second-year medical pharmacology course.⁴ The researchers evaluated individual and group answers to all IRAT and GRATs, concluding that TBL approaches were more effective than traditional learning methods. While TBL appeared to improve student understanding of difficult concepts, the authors felt the method was not more effective for learning simpler concepts.

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Another advantage of implementing TBL, especially in health professions education, is the opportunity to acclimate students to working in teams. In the health professions, it is common for physicians, pharmacists, nurses, and other medical professions to work closely together to solve complex medical problems. Using TBL methods in the classroom, where students practice listening to one another and sharing knowledge to solve challenges can prepare students for collaborating with health profession colleagues throughout their careers. Overall, TBL not only improves academic performance and students’ understanding of difficult concepts, it gives students an opportunity to practice the team-work skills they will need throughout their careers.

The potential advantages of the TBL method provide enough justification for health profession educators and programs to implement this learning technique. Health professions educators can implement TBL techniques by simply requiring students to self-prepare outside of class and reserving class time for group interaction.  To hold student accountable for pre-class work, it is important to use reinforcement examinations. This pre-class work is critical for the discussions and application exercises to be successful.

However, there are a few logistical issues that educators should consider before implementing TBL in their courses. First, educators must consider how they will form student teams. In order to develop group cohesion, TBL groups should remain the same throughout the duration of the course. Ideally, teams should be strategically formed based on three principles: 1) teams should be assigned by the instructor - not student-selected; 2) teams should be as diverse as possible; and 3) the selection process should be transparent.⁵ Implementing these principles allows the development of diverse groups that bring different strengths and experiences to the discussion and application exercises. In addition to discussing how team assignments were made, educators must orient students to the TBL method by explaining pre-class preparation, application exercises, and the readiness tests. Ensuring that students have a complete understanding of TBL and its benefits is essential for students and co-instructors.  Getting everyone’s commitment is critical when implementing a novel teaching approach. Using the principles of instructional design, considering the design, development, and implementation of each instructional unit, are fundamental to the success of TBL. 

References:

1. What is TBL?. Team Based Learning Collaborative. Published 2019. Accessed October 23, 2019.
2. Brame C. Team-based learning. Vanderbilt University. Published 2019. Accessed October 23, 2019.
3. Koles, P. et al. The Impact of Team-Based Learning on Medical Students’ Academic Performance. Academic Medicine 2010;85(11): 1739-45.
4. Zgheib N. et al. Using team-based learning to teach pharmacology to second-year medical students improves student performance. Medical Teacher 2010;32(2):130-5. 
5. Getting Started with TBL. Team Based Learning Collaborative. Published 2019. Accessed October 24, 2019.

Generational Differences and Its Impact on Teaching and Learning

by Hannah Daniel, PharmD, PGY-1 Pharmacy Practice Resident, University of Mississippi Medical Center

People from different generations routinely interact in higher education today and generational differences impact the learning environment. Members of Generations Y, also known as Millennials, and Z make-up the majority of the health professional students with most faculty members being members of earlier generations, primarily Generation X and Baby Boomers. The learning environment is significantly different for each generation. Millennials are accustomed to instant gratification, technologically advanced learning, and interactive activities aimed at providing lots of stimulation to stay engaged. Generation Z is accustomed to even higher levels of digital technology and connectedness, which will potentially lead to greater expectations for customized instruction for each student.¹ With so much focus on technology and the need for constant stimulus, faculty members are challenged to teach in ways that are quite different from the ways they were taught. Marc Prensky in his essay about the differences between digital natives and digital immigrants makes an intriguing point: “Today’s students are no longer the people our education system was designed to teach.²” Current literature suggests we should be adapting to the learner; however, it is unclear if learning outcomes are improved.  This raises an important question:

“Should teachers make adjustments in their teaching methods to accommodate students from a different generation?”

To understand some of the generational differences between students and faculty, one can compare leadership style preferences between generations. In 2018, the American Journal of Pharmaceutical Education (APJE) published an article about leadership styles reflecting generational differences in the academy. The four leadership styles they described included:

• Classic entrepreneur: Competitive and opportunistic
• Modern missionary: Looks for significance and meaning to promote impact
• Problem solver: Focuses on concrete results; values top-down experiences and a “take-charge” approach
• Solution finder: Modest and humble

Baby Boomers, those primarily exposed to male and military leaders, tend to lean towards a problem solver style. On the other hand, Millennials have a tendency to lean towards a modern missionary or solution finder style.³ The difference in styles also reflects learning styles. Baby Boomers thrive on concrete information and structure while Millennials strive for more hands-on and less structured approaches.

The majority of current faculty were taught in a traditional and passive manner.  They were encouraged to read the material and to take notes in class. Although these methods of learning are effective, today’s students struggle to learn in this environment due to a strong desire for hands-on and more interactive methods. Some programs have transitioned away from teacher-centered approaches to more learner-centered methods, such as problem-based learning, to adapt to a new generation of learners. A major reason to adapt teaching methods is premised on the idea that “successful students are those that are engaged during the learning process,” which means using strategies that motivate your students. One study conducted at Creighton University in Nebraska compared pre-test scores vs. post-test scores and average time spent on a case between an interactive computer-based case and a standard paper-based approach. While students assigned to the computer-based case group scored slightly higher on their pre-test and post-test and spent less time on the case, none of these results were significant.¹

However, not all students in the same generation share the same learning preferences. Some students learn best in traditional ways while others learn best when interactive methods are employed. Thus, it can be argued that adapting teaching styles to match students’ preferences is not infeasibility or wise. Moreover, exposing students to different learning methods will challenge them, leading to better educational outcomes, and teaching them to be more adaptable. In a study conducted at Texas Tech University Health Sciences Center School of Pharmacy, students on rotation and preceptors completed the validated Pharmacist’s Inventory of Learning Styles (PILS) questionnaire to identify their dominant learning styles. The investigators found that, although this information helped guide the preceptors to challenge students, it did not impact student or preceptor performance — even when the preceptor adapted his/her teaching methods to better align with the student’s preferred learning style.⁴ Even though this study did not specifically address classroom-based instruction, it provides some insights regarding the use of individualized instruction using the student’s preferred learning style as well as their non-preferred styles.

It seems clear there must be a compromise between students and educators. Educators should not be expected to change their entire way of teaching.  Similarly, students should not be expected to change their entire way of learning. Educators can incorporate active learning strategies into their traditional lectures to increase motivation and engagement. By adding versatility to their teaching repertoire, educators will be able to reach a wider range of students.¹ Examples of active learning that can be incorporated into a lecture include the following:

• Problem-solving exercises
• Think-pair-share
• Short demonstrations followed by a class discussion

It is also useful, after lecturing for 20-30 minutes, to pause for five to ten minutes, allowing students to work together in pairs or groups to recall, clarify, and elaborate on the material before moving forward. Another way to engage students is to ask five to ten questions related to the most pertinent material from the previous class session to stimulate recall before the start of class.⁵

There are generational differences between students and educators, leading to different learning preferences. Although impractical for educators to tailor their teaching methods to each student’s learning style, it is important for all, students and educators alike, to acknowledge the changing dynamics between generations and be open to all styles of learning. Again, “successful students are those that are engaged during the learning process,” but responsibility for engagement does not fall solely on the educator. Educators should not make major adjustments to what they do but rather find common ground. Students should be open to different ways of learning to challenge themselves and increase their adaptability.

References:

1. Pick A, Begley K, Augustine S. Changes in teaching strategies to accommodate a new generation of learner: A case study. Pharm Educ. 2017;17(1):95–99.

2. Prensky M. Digital natives, digital immigrants. MCB University Press, 2001. Accessed 31 October 2019.
3. Boyle CJ, Gonyeau M, Flowers SK, et al. Adapting Leadership Styles to Reflect Generational Differences in the Academy. Am J of Pharm Educ. 2018;82(6): Article 6886. doi.org/10/5688/ajpe6886.
4. Robles J, Cox C, Seifert C. The impact of preceptor and student learning styles on experiential performance measures. Am J Pharm Educ. 2012;76(7): Article 128. doi:10/5688/ajpe767128.
5. Promoting active learning. Standford: Teaching Commons. Accessed 4 November 2019.