Team-based care is one of the foundations of health care delivery. Until recently, however, the nurturing of teamwork mindsets and skills has not received sufficient attention in the formal professional education of clinicians. In physician assistant curricula, the situation is beginning to improve. For example, within the University of Washington’s Physicians Assistant Program (MEDEX), Team-Based Learning (TBL) is getting students more actively engaged in the learning process. It offers students opportunities to do more than sitting passively, listening to professors profess, and being anything but actively engaged in the learning process.
Team-Based Learning offers the means to get students more actively engaged in and accountable for their learning. It encourages them to more consistently prepare for class so that as a group, they arrive with the basics under their belts. It recognizes their preclass preparation and awards them course credit for doing so. It increases the likelihood that the majority of students will arrive for TBL sessions at similar levels of understanding, ready to contribute to team-based activities aimed at more fully understanding the importance of the day’s basic content and concepts. Most important, the majority of in-class TBL time can be devoted to providing opportunities for students to apply that which they have learned to challenges and problems that are directly relevant to their professional development.
Team-Based Learning Defined
The concept of TBL was brought to the forefront of professional education in the late 1970s by Larry Michaelsen. He was seeking to provide a better forum for instructors to share the benefits of their expertise with students while at the same time enabling students to enjoy the benefits of small-group learning within large classes. Over the past few decades, TBL has steadily gained traction in clinical education programs throughout the United States, Canada, and Europe.
Team-Based Learning is a proven method of instruction that typically takes place in large classroom wherein small groups or teams are formed to solidify and provide practice applying independently learned material. Team-Based Learning involves preclass study and preparation (usually readings, occasionally voice-over PowerPoint presentations), accountability-focused individual and group and team assessments, and in-class learning activities (application exercises). The application exercises are designed to provide students with practice applying newly encountered concepts to clinically relevant challenges and problems.
The team-based application activities are followed by simultaneous feedback-oriented assessments of the outcomes of the application exercises and by opportunities for the instructor(s) to clarify any misunderstandings that may have become evident during the application exercises. Last, opportunities are provided for the instructors to share their expertise via question and answer sessions that have as their goal to help students fully understand the material and get all of their questions answered.
Typically, TBL consists of
A period of independent preclass preparation for which students will be held accountable
In-class individual and group readiness assurance (RA) tests (short quizzes)
Postgroup quiz team appeals (if necessary) that may impact how quiz points are calculated
In-class application exercises that enable the teams to simultaneously apply the day’s content and concepts to related problems and challenges
Extemporaneous “mini” lectures, if needed, to clarify any misunderstandings that may have been overheard or observed by the instructor(s)
Postapplication exercise question and answer sessions (expertise sharing) led by the instructor(s)
In TBL, students are expected to prepare before coming to class, and they are held accountable for doing so. Students and their teams are also held responsible for figuring out the basic content and concepts at the “knowledge” and “comprehension” levels of Bloom’s oft-cited taxonomy of learning domains ( Fig. 56.1 ).
In professional education, lectures and assigned readings most often cover concepts from the “knowledge” and “comprehension” domains of Bloom’s taxonomy (see Fig. 56.1 ). The same is true for TBL readings. The difference is that in TBL, the material is not lectured upon. On the contrary, the majority of class time is devoted to
Accountability determinations, or RA)
Team teaching, meaning that team members work together to bring each other up to speed on the day’s concepts by informally teaching one another
Completion of content and concept application exercises focused at the level of Bloom’s “application” domain
The entire TBL process is designed to place more responsibility on students for their basic learning, to provide a better structure for instructors to share their expertise, and to get students more actively involved in and accountable for their learning.
Why Team-Based Learning? Clues that Lectures may not be Working
Lectures have come to be recognized as relatively poor platforms for instructors to share their expertise. When straight lecturing is the planned in-class modality, too many students view it as not being a good use their time. The problem is that the one-way communication of lecturing does not typically capitalize on the best avenues through which adults learn complex material.
In professional schools, if allowed, students tend to vote with their feet. If lecture attendance seems to be decreasing, then students may not view attending them as a good use of one of their most valuable resources—namely, their time. Because reading assignments are too often so extensive, much of the readings don’t get read. This problem is compounded by the fact that each time preclass readings don’t get read beforehand, the likelihood diminishes that most students will have time to go back and complete the readings. As a result, lecturers cannot rely on most students completing the assigned readings. As a result, students seem to feel obligated to regurgitate material that was actually embedded within the assigned readings, although it is difficult for students to identify which parts of the reading assignments were most important. Because lecturers too often think that they need to spend class time lecturing on the key points, they have little time left to reflect on the content, to offer suggestions to students on how to best learn the material, to share the many insights they have formed that are relevant to the content of the day, or to provide time.
Bottom line: If you don’t believe that when lecturing you have enough time to give your students the benefit of your expertise and thinking, if your top students seem to be bored or they don’t regularly attend class, or if your struggling students seem to be getting further behind, then the lecture approach may not be working for you. It may be time for you to give TBL a try.
The Rationale for Team-Based Learning
There are several key reasons why interest in TBL has grown so much in recent decades. The first is that TBL is more in line with the way adults learn. It provides opportunities for professional students to encounter content in the contexts in which they will later use it. More important, TBL provides opportunities to practice applying new concepts immediately after students’ exposure to it. This helps learners recognize the relevance of newly encountered materials to their future practice as clinicians.
Cognitively challenging material demands deliberate study. The structure of TBL encourages students to do at least a minimal amount of preclass preparation. With a relatively small amount of preclass reading, students can expect to do well on the RA quizzes. More important, by completing the preclass readings, students become prepared to be productive members of their teams.
Reading assignments that are excessively large can be overwhelming. This is particularly true for students who tend to fall behind on their readings as classes progress. When an individual’s backlog of readings begin to stack up, it becomes more and more difficult for him or her to keep up. In TBL, as with lecturing, falling behind in readings is a problem.
The benefits of TBL in the health professions are relatively well documented. A number of important outcomes become possible during TBL beyond content coverage. While engaged in the TBL process, students not only cover content, but they also develop self-study skills, teamwork skills, interpersonal skills, communication skills, lifelong learning skills, and critical thinking skills.
Research suggests that TBL is capable of improving student performance in both academically weak and academically strong students. It has also been shown to be useful for providing small-group experiences in a large class situation without needing a large number of faculty members. It has been shown to enhance knowledge transfer; temporarily improve test performance over levels obtained by the lecture format; and increase communication, teamwork, teaching skills, and overall decrease failure rates. It has recently been reported that students in TBL favor many aspects of the TBL process, and many report experiencing increased motivation to do prereading to assure readiness to more effectively engage in the process. Students, however, tend to highlight the need for more time within TBL for clinical problem solving as in problem-based learning formats.
Overview of the Team-Based Learning Process
The TBL process was envisioned in the late 1970s by Larry Mickelson as a way to enable faculty to have students focus on applications rather than on content that had been typically delivered via lectures. Having students begin each TBL session with the same basic level of understanding of the content is essential to the process. Its three-phase process is relatively straightforward ( Fig. 56.2 ).