Team-based learning in a medical gross anatomy and embryology course

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  • MEDICAL EDUCATION

    Team-Based Learning in a Medical Gross Anatomy andEmbryology Course

    GARY L. NIEDER,1* DEAN X. PARMELEE,2 ADRIENNE STOLFI,3 AND PATRICIA D. HUDES2

    1Department of Anatomy and Physiology, Wright State University School of Medicine, Dayton, Ohio2Ofce of Academic Affairs, Wright State University School of Medicine, Dayton, Ohio3Department of Pediatrics, Wright State University School of Medicine, Dayton, Ohio

    The application of team-based learning (TBL) as a major component of a medical grossanatomy course was evaluated. TBL is a method of small group instruction that addressessome of the shortcomings of other small-group teaching approaches. The core components ofTBL were instituted in 12 small group sessions in the course. Each session includedobjective-oriented assignments, an individual readiness assurance test, a group readinessassurance test and a group application problem. Peer evaluation was carried out on a regularbasis. Scores from TBL session activities and course examinations were analyzed andcompared to previous years course performance. Student course evaluation data and facultyfeedback were also collected. Student evaluation data and faculty response indicated strongsupport for the TBL method as it was implemented in the course. Faculty noted improvementsin students day-to-day preparedness and group problem solving skills. Students mean scoreson exams were not signicantly different from those of previous years. There was, however,a signicantly smaller variance in examination scores that was reected in a lower coursefailure rate compared to previous years. Correlation analyses of TBL and examinationperformance suggested that individual readiness assurance test performance is a goodpredictor of examination performance. TBL proved to be a superior method for small grouplearning in our anatomy course. Student performance suggested that TBL may most benetacademically at-risk students who are forced to study more consistently, are provided regularfeedback on their preparedness and given the opportunity to develop higher reasoning skills.Clin. Anat. 18:5663, 2005. 2004 Wiley-Liss, Inc.

    Key words: gross anatomy; education; team-based learning; medical education

    INTRODUCTION

    Instructors of anatomy have recognized the impor-tance of clinical application, active learning, and groupproblem solving in medical education and there havebeen numerous strategies employed to develop theseskills (Schwartz, 1989; Scott, 1994; Holla et al., 1999;Geuna and Giacobini-Robecchi, 2002; Miller et al.,2002). We strive to promote active learning in thegross anatomy and embryology course (Human Struc-ture) at our institution. The course has been centeredaround a full dissection lab and 23 case-based smallgroup sessions supported by web-based materials andrelatively few traditional content-based lectures(Nieder and Nagy, 2002). The small group sessions,designed to review anatomical content via case prob-lems, have suffered from poor attendance, variablestudent preparation and inconsistent group problem-

    solving achievement. Although some students consis-tently attended the small group sessions and ratedthem highly in terms of helping them learn anatomy,the overall rating of the sessions has been mixed.Faculty in the course would concur that, despite spe-cic preparatory assignments, few students come trulyprepared to engage in active discourse and that toomuch time is spent in the sessions covering basicfactual material rather than in applied problem solv-ing.

    *Correspondence to: Dr. Gary L. Nieder, Department of Anatomyand Physiology, Wright State University School of Medicine, Day-ton, OH 45435. E-mail: gary.nieder@wright.edu

    Received 24 July 2003; Revised 26 February 2004; Accepted 2March 2004

    Published online in Wiley InterScience (www.interscience.wiley.com). DOI 10.1002/ca.20040

    Clinical Anatomy 18:5663 (2005)

    2004 Wiley-Liss, Inc.

  • We explored strategies for making our small groupsessions more meaningful and decided to try team-based learning (TBL), a teaching method rst devel-oped and described by Michaelson et al. (1997) forlarge classes in business school and adapted for lim-ited use in basic science and postgraduate medicaleducation at Baylor College of Medicine (Seidel andRichards, 2001; Haidet et al., 2002). Team-basedlearning has many features that make it applicable toundergraduate medical education courses in the pre-clinical sciences: it is a very active learning processthat promotes both the learning of factual material aswell as higher-level cognitive skills; it uses smallgroups (teams), and requires team members to workcollaboratively; faculty are more engaged with thestudents than in traditional lecture or even many othersmall group formats and they know quickly what theirstudents are achieving; it requires consistent studentpreparation and attendance; it gives students an op-portunity to learn a great deal about working withinteams and how to evaluate themselves and their peersthrough peer evaluation; it requires fewer faculty thantraditional small group exercises or problem-basedlearning.

    For the academic year 20022003, we institutedTBL in the small-group component of the course.TBL had not previously been implemented as a majorgraded learning component in a medical basic sciencecourse, but from experiences in other academic elds,we hypothesized that students would be better pre-pared and nd the sessions more effective than ourprevious small group sessions. We hoped that becausethe TBL strategy forces students to keep up with thecourse material, academic performance (exam scores)of all students would improve, in comparison to pre-vious years.

    We describe the implementation of TBL into theHuman Structure course and present the results of anend-of-course evaluation, which explored the studentexperience with TBL, data on student performanceon individual and group TBL activities and examscores. Three faculty members were responsible forthe conduct of the TBL sessions and their experiencewith this different approach is also described.

    MATERIALS AND METHODS

    Establishment of Teams

    The 97 students in the rst-year medical class wereassigned to 18 teams of ve or six students each. Theassignments were randomly generated except thatprovisions were made to prevent single gender teams.Students were informed that their team assignments

    would remain the same throughout the year. Twostudents did not complete the course (performanceanalyses are based on n 95).

    Team-Based Learning in the Course

    The Human Structure course included multipleteaching modalities including traditional live em-bryology lectures, on-line gross anatomy lectures(web-based slide shows with audio streams; Niederand Nagy, 2002), dissection lab and computer-aidedinstruction on sectional anatomy and imaging, includ-ing the Beyond Vesalius program and photo-based vir-tual reality programs developed at this institution(Nieder and Nagy, 1996; Nieder et al., 2000). Threeanatomy department faculty delivered the basic anat-omy and embryology lectures (live and on-line),taught in the TBL sessions and covered the dissectionlab. Seven clinical faculty presented clinical correla-tion lectures and a graduate teaching assistant pro-vided off-hours assistance in the lab. Students werescheduled for 140 hr of instruction (live lectures, laband TBL) during the 9-week course. Because this wasthe only major course during this time, students hadample time for the independent learning aspects ofthe course (on-line lectures and other computer-aidedinstruction, reading, and lab review).

    Twelve TBL sessions were scheduled into the9-week timeframe of the course. Each 2-hr sessionincluded the typical elements of TBL including pre-paratory assignments; Individual Readiness AssuranceTest (IRAT); Group Readiness Assurance Test(GRAT), and Group Application Problem (GAP).Peer evaluation, contributing to the course grade, wasalso included in the plan. Team-based learning activ-ities comprised 25% of the course grade, whereasthree major examinations contributed the remaining75%. Students were required to score a 70% averageon the three exams (without the TBL component) aswell as a 70% overall course grade (including the TBLcomponent) to pass the course.

    A group consensus process determined the contri-bution of various TBL activities to the TBL grade onthe rst day of class. Students were asked to dene aweighting system for individual performance (theIRATs), group performance (GRATs and GAPs) andpeer evaluation. A constraint was that each portionmust contribute between 2060% of the total TBLgrade. The distribution emerging from this consensusprocess was 20% individual performance, 50% groupperformance, and 30% peer evaluation. Each stu-dents TBL grade was calculated using this distribu-tion.

    The 18 teams were divided into six groups of threeteams (1516 students total) each meeting in physi-

    Team-Based Learning in Anatomy 57

  • cally separate sessions. The limited number of facultyin the course required us to hold two simultaneoussessions at three times during the day to cover allstudents in the class.

    Design of the TBL SessionsAssignments. One week before the session, spe-

    cic assignments were posted on the course web site.These included live and on-line lectures, textbookreadings, computer exercises in sectional anatomy andimaging and dissection lab sessions. Along with theassignments, students received a list of objectives forthe session. The TBL sessions were scheduled toallow adequate time for students to complete theassignments and study for the session.

    Individual readiness assurance test. At the be-ginning of the session, a 10-question, closed book,multiple-choice quiz was administered with a 12-mintime limit. Questions on the Individual ReadinessAssurance Test (IRATs) were focused on the factualcontent from the assignments and required only lim-ited reasoning or problem solving. The answers wererecorded on computer bubble sheets for later grad-ing.

    Group readiness assurance test. Immediatelyafter the IRAT, the same quiz was administered to theteams, with a 20-min time limit. The teams came toconsensus answers and responded on bubblesheets, also graded after the session.

    RAT question discussion. Questions were re-viewed by having the teams simultaneously showtheir answer using lettered cards. If team answers didnot agree, the discrepancies were addressed by askingthe teams to defend their answers. Once any misun-derstandings of content or errors in reasoning wereresolved, the instructor would move to the next ques-tion. If all teams displayed the same answer, the in-structor asked if there were any lingering questionsabout the question or related content. If there were noissues, the instructor would either move directly to thenext question, or might raise a secondary question tostimulate additional discussion. This discussion phasewas scheduled for 25 min to complete the rst hour ofclass.

    Group application problem. Teams were givenone or more clinical cases related to the days topicwith an accompanying set of multiple-choice ques-tions. The cases included text describing the patientshistory and physical examination ndings. In somecases, additional data in the form of X-ray, CT, MRI,ultrasound images, or videos of the patients symp-toms were delivered via computers in the TBL ses-sion rooms. The cases and questions were crafted torequire integration of anatomical facts and concepts

    and a substantial amount of reasoning. Students hadaccess to an anatomy atlas and medical dictionary, butno other books, notes, or online resources. Teamswere given 30 min to work through the cases andrecord their answers. Questions from the group appli-cation problem (GAPs) were reviewed in a mannersimilar to the RAT question review.

    Peer evaluation. At three points in the course,coinciding with the major examinations, studentswere required to ll out peer evaluation forms formembers of their team. Peer evaluation consisted oftwo separate forms. The rst form required studentsto allocate a xed number of points (10 the numberof team peers) to their team peers with the stipulationthat not all team peers could receive 10 points. Thisform, which was used as the peer evaluation compo-nent of the TBL grade, also requested a justicationfor the low and high scores assigned. Students wouldonly receive their average peer evaluation score fromthese forms. A second form, used as a formative eval-uation, required students to rate their peers in variousaspects of cooperative learning skills, self-directedlearning and interpersonal skills. Anonymous ratingsand specic written comments were returned to thestudents. The faculty did not see these forms or usethe information from this second form in grade deter-mination.

    Student Evaluation of TBL

    The end-of-course evaluation gathered numericaldata and comments about every aspect of the HumanStructure course. A section of the evaluation, specicto the TBL component of the course, included sevenitems for graded response and solicited suggestions forimprovement. All students completed the evaluationform before concluding the nal TBL session.

    Faculty Evaluation of TBL

    Three full-time faculty participated in the imple-mentation of TBL for the Human Structure course.They have all taught in the course for over ten years,conducting lectures, lab dissection, and small groupinstructions. Their comments about substituting TBLfor the previous small group instruction format wererecorded.

    Statistical Analysis

    Examination scores from 2002 were compared tothose from 19992001. These were calculated fromthree major exams each consisting of a written board-type multiple choice portion (100 questions) and apractical including identication and secondary ques-tions (50 questions). In constructing the written andpractical exams, we made efforts to assure we were

    58 Nieder et al.

  • testing the content to a consistent breadth and depth.The written exams were constructed from a commonpool of questions, but for security reasons were notidentical from year to year. Practical exams made useof the students dissections, so were likewise differentfrom year to year as well. The N (number of studentscompleting the course) for each year were: 91 in 1999;94 in 2000; 91 in 2001; and 95 in 2002. Examinationscores were analyzed by the modied Levene equalvariance test (F-test) to determine whether the vari-ances in the groups are equal, followed by the Welchtest ANOVA for unequal variances. Correlations be-tween TBL scores and exam results were analyzed bylinear regression. Statistical analyses were carried outusing StatView (SAS Institute, Cary, NC) and NCSS(Kaysville, UT).

    RESULTS

    Student Evaluation of TBL

    When asked to rate the various learning venues andresources in the course (Table 1), 83% of our studentsagreed or strongly agreed that TBL was helpful totheir learning. Only the dissection lab and onlineresources (online supplemental lectures, video dissec-tion guide, exam question bank, etc.) were rat...

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