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.

Icons made by Vectors Market from www.flaticon.com

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.