It is well known that the success of medical education depends on how to combine theoretical education with clinical training [9, 12]. We optimized the TBL model in case discussions during the clinical probation of infectious diseases from 2015 to 2018 and compared with CBL. Between the TBL and CBL groups, no significant difference in students’ score of theoretical exams before clinical probation (Table 1).
In our study, fourth-year medical students indicated that both the TBL and CBL teaching procedures were easy to follow. The 2 teaching models had clear teaching objectives, and emphasized critical thinking. The key points of session topics were highlighted by tests. Furthermore, our results supported that TBL more effectively improved students’ initiatives for preview, and motivated case discussion, team spirit, and collaboration. Significant differences were observed between TBL and the CBL group (Table 3) (all, P < 0.05). The results also showed that the success of TBL substantially relied on preparation based on instructor-assigned materials before the TBL session, which is consistent with the findings of Burgess et al. [7]. Being informed about the topics days before discussion, students had sufficient time to preview related theories. Because iRAT and gRAT require students to apply the knowledge acquired in preparation, problems, and clinical scenarios, TBL further promoted active learning before the session. Selected cases and iRAT/gRAT questions were closely related to the teaching topic, which helped to train differential diagnosis thinking and provided more engagement during class and more responsibility for their own learning. Lochner et al. [16] and Chen et al. [17] also thought that performing individual and group assurance tests with immediate feedback in TBL encourages students to prepare themselves before class, and contributes to case discussion. Student performance and perception were improved by the implementation of TBL. Moreover, teams remained the same for all TBL sessions, and gRAT indicated improved team spirit and collaboration.
On the other hand, in 2015 there were no significant differences in final examination scores between the 2 teaching models (Table 4). This may be because there were only 100 fourth-year medical students enrolled, with 50 students in each group. As TBL was used for the first time for case discussion in clinical probation of infectious diseases, we believe the experience of teachers was insufficient in the initial stage of the study. Rezende et al. [18] reported that students did not attain better scores after TBL as compared to traditional lectures. However, Yan et al. [19] reported TBL enhanced examination scores.
Based on the aforementioned information, we did not think the stud of 2015 provided a sufficient trial of TBL. Therefore, in the study from December 2016 to April 2018, there were 239 students in the optimized TBL model group, and 213 students in the CBL group. As shown in Table 4, the final examination scores of students in the optimized TBL model group were significantly higher than those of the students in the CBL group (t = 2.310, P = 0.021). This finding is consistent with that reported by Carrasco et al. [13]. The assessment incentives and methods used in TBL results in student performance that better predicts performance on summative examinations. Meanwhile, we also noticed that the mean difference was small between the 2 groups (85.8 vs. 84.8) (Table 4). This further confirmed that continuing these efforts positively impacted student assessment of TBL as a process, and increase student appreciation for TBL. Being better prepared for class, more engaged during class, and more responsible for their own learning were encouraged. Students had a more positive perception of team and teamwork, which is consistent with the results of Burgess et al. [7] and Kibble et al. [20]. Carrasco et al. [21] also pointed out the importance of using different TBL grades and incentive structures so as to foster the development of well-rounded physicians. Students need long-term learning to improve their practical problem-solving ability.
Our study extended beyond traditional teaching methods which center on teaching, but ignores students' learning initiatives. Although this was a single center and single discipline study, it is the first time TBL was used for case discussion in clinical probation of infectious diseases. Given this success in our department, we encourage that TBL is used more in the clinical training of different medical disciplines. More students, more accurate quantitative scores, and longer-term observation will be necessary to further evaluate TBL in the future.