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Subjects and Methods 

Subjects

   This study was conducted on 29 undergraduate medical students had completed the Growth and Development (G&D) block in 2019, which is given at Year 2. This course was taught in five weeks. The student studied four problems through PBL and three subjects through TBL. The study was carried out at the College of Medicine, Najran University.

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Methods

   The college adopts an integrated hybrid problem based learning system through a group of well-organized curriculum (blocks) based on horizontal and vertical integrated topics. The block evaluation is carried out through formative and summative assessment. The formative assessment is represented by a weekly quiz that includes multiple choice (MCQs) and short essay questions. The summative assessment includes a final theoretical exam, which consists of MCQs and a final practical test which include a group of OSPE or OSCE stations.

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Structure of problem based learning

   Four objective based constructed problems were discussed in the G&D block in small student groups; each group was 9 or 10 students. Every problem spanned through one academic week (from Sunday to Thursday) and discussed in two sessions. In the first session, the problem was presented to the students to extract the intended learning objectives for further studying through self-reading and lectures with guidance of a tutor. After self-study, students of each group meet again to discuss the extracted objectives in what is known "outcome session", in which the students listen to each other to present what they have learned, to exchange knowledge, and to discuss the unclear topics. The tutor plays an important role as a facilitator by encouraging and boosting the discussion among students.

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Structure of team based learning

   Before the TBL session, the students were given the objectives and contents of what would be discussed later. We created 5 permanent teams, each of five to six students. The teams were characterized by the converging representation of students' levels. For each TBL session, students first take an individual readiness assurance test (iRAT), which is a short multiple-choice quiz. The iRAT holds each student accountable for learning the material and decreases the likelihood of social loafing. Once students have completed the iRAT, they complete a group readiness assurance test (gRAT), which is the same multiple-choice quiz they completed individually that generate the discussion among the teammates followed by immediate feedback led by the content expert. Students then moved on to the case-based problem-solving activities "group assessment" that were based around the same subject.

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PBL and TBL assessment

   Student’s performance in PBL sessions for each problem was evaluated as follow: session 1: (discussion session) was evaluated according to the student ability to extract the intended learning objectives, peer- interaction and attendance. Session 2: (outcome session) was assessed according to the quality of presentation and scientific content, peer-interaction and adding new information. Student’s performance in TBL sessions was calculated according to the cumulative scores of iRAT (60%), tRAT (20%) and group assessment (20%).

   The results of PBL and TBL were correlated to the final theory and practical exams to ensure their effectiveness as assessment methods to complement their effectiveness as teaching methods.

Statistical analysis

   The collected data was tabulated, and analyzed statistically using the SPSS statistical software (IBM SPSS Statistics 20). Statistical difference was considered significant if the P-value was less than 0.05 and highly significant if the P-value was less than 0.001.

RESULTS       

    TBL assessment showed a highly positive correlation with quizzes, final theory and final total degrees (P = 0.004, 0.009, 0.003) respectively, and a positive correlation with final practical exam (P = 0.026) [Table 1]. On the contrary, PBL assessment did not show any correlation with any of assessment methods [Table 2].

Figure 1: TBL showed positive correlation with quizzes, final theory, final practical and total degrees.​

DISCUSSION

It is important to ensure that the evaluation methods of different teaching methods are reliable. In our study, we have compared the results of problem-based learning with the quizzes and final exams' results, which based on a matrix on which all parts of the curriculum are represented in proportions consistent with the academic load.

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   We found that the PBL evaluation marks did not always reflect the learning outcomes and the intended level of understanding was not always measured properly. In addition, the teacher and students thought that the assessment criteria were unclear, which in turn led to the unreliability of the assessment. These problems led to perceptions that the assessment was unfair. The results imply that grades should be critically evaluated as indicators of the quality of learning outcomes [8].

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   This does not mean that PBL is not valid as a learning model, but the reevaluation and modification of the assessment process is required. The students acquired many skills through PBL, other than gain of knowledge only, as in traditional education, such as research and self-study skills, that guarantees the ability of continuous update. In addition, PBL promotes student self-confidence through peer-discussion, argumentation and presentation. The students also acquire the skills of communication, collaboration and teamwork.

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   Several studies reported the merits of PBL as an innovative educational approach focused towards the students in which they decide what need to learn [9, 10], and achieve the competencies required by medical graduates that encompass the ability to effectively collaborate, communicate and problem solve. As graduates must be lifelong learners, capable of accessing, assessing and synthesizing a wealth of information relevant to health care [11, 12].

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   PBL offers a great tool for students’ self-instruction. The behavioral theory on self-regulation includes students’ self-instruction as well as their responsibility for an ongoing monitoring of their own progress that encourages their critical thinking, imagination, and engagement [13, 14]. We have seen some flaws in PBL, which made us look for alternatives or pillars that support these deficiencies such as TBL. One of these major disadvantages is that the intended educational goals are distributed on students for self-studying, and each student prepares his educational goal only without the subject being prepared as a whole. In addition, sometimes the choice of the problem subject does not suit the week theme and this matter can be avoided by choosing the appropriate subject.

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   Another problem faced us was the unreliable evaluation process so far, it does not correlate the other evaluations despite numerous attempts to avoid this matter. Glew (2003) was believing that several reasons may explain why PBL has failed to achieve its expectations, of them, inadequate support of the curriculum from basic scientists who do not support the concept itself, poor oversight and inadequate implementation and assessment [15].

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   In addition there is a serious problem that results from inadequate implementation is the missing of some topics. A previous study showed that PBL is not appropriate for gaining systematic knowledge of a subject, as students would fill the gaps left in the knowledge base later during their career [16]. Another issue makes PBL application more difficult is the time shortage. The average of actual study time during the last five academic years was 40 months, which is insufficient time for medical program. On the contrary, it was found that student contact hours are four times greater in PBL than for traditional learning [6, 17].

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   These problems made us to engage the team-based learning as one of our program educational modalities, and it may be an alternative of other learning and teaching methods in the future if it proves to be the optimal educational model. Team-based learning (TBL) is an attractive instructional approach especially for the acquisition of teamwork skills [1]. TBL shifts the focus of instruction from the teacher as dispenser of information to student centered activity to foster the development of self- learning and team collaboration [7].

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   TBL can evaluate the student performance and understanding of the pre-session assignments through iRAT [18], and assess the student's benefit of the receiving immediate feedback from the gRAT [19], as both mechanisms "pre-session assignments and session feedback" are essential to consolidate information and concepts. Unfortunately, the feedback process was often lacked in PBL, errors may go uncorrected, and a students’ sense of being “lost” with new content is amplified [20]. As the PBL tutor is often not specialized in the subject of study, unlike the TBL facilitator must be specialized.

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   This study showed that TBL assessment is reliable in assessing the students level, TBL showed a highly positive correlation with quizzes, final theory and final total degrees (P = 0.004, 0.009, 0.003) respectively, and a positive correlation with final practical exam (P = 0.026). [Table 1] A previous study indicated that students found more advantages of TBL over PBL including better engagement in learning, deeper understanding of concepts, and a sense of responsibility towards teammates [21]. Another advantage of TBL is that one facilitator runs the session for all groups in one class, while in PBL there must be a tutor and class for each group [1]. The aforementioned does not detract from PBL its merits, as it was the seed of student-centered learning from which many modalities split. In addition, it still has the benefit of discussion before self-study in which students activate their prior knowledge, a strategy that has positive cognitive effects on learning [22, 23].

CONCLUSIONS  

   The assessment results of TBL are reliable, while of PBL is not. TBL showed a positive correlation with quizzes, final theory and practical exams and final total marks, while PBL assessment did not show any correlation with any assessment method. In addition, the integration of the two learning modalities "PBL & TBL" has a synergistic effect in order to boost the success of the educational process. 

ACKNOWLEDGEMENT  

   The  author  would  like  to  thank  Prof. Dr. Mohamed S. Zayed, Dean of the College  of  Medicine, Najran  University and Dr. Moawia A. Alshiekh for  their all support provided.

DISCLAIMER

The article has not been previously presented or published, and is not part of a PhD or thesis project.

CONFLICT OF INTEREST

There are no financial, personal, or professional conflicts of interest to declare.

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