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Byline: Sadia Hameed, Tanzeela Khalid, Shazia Aslam, Mubashir Ahmad, Faiza Farhan, Zahra Batool and Saima Hamid


Objective: The objective of this study was to compare the impact of team based learning (TBL) on student`s test scores in comparison with didactic lectures. We also wanted to assess to the level of students satisfaction regarding TBL as a teaching methodology.

Study Design: Quasi experimental study.

Place and Duration of Study: Department of Pathology, University Medical and Dental College Faisalabad, from May to July 2013.

Material and Methods: Fourth year undergraduate medical students attending Pathology course at University Medical and Dental College (UMDC), Faisalabad in year 2013 involved the portion of Haematology were divided into two halves. The first half (H-1) was covered in two TBL sessions of two hours and 15 minutes duration each. The second half (H-2) was covered in 8 lectures of 45 minutes duration each. After completion of the course, students took test comprising of problem based SEQs regarding Hematology. The test comprised of two segments with questions of equal difficulty, representing the two halves of the topic. Students' scores in these two segments were compared by using paired sample t-test. The students were given a validated questionnaire. This data was analyzed by using SPSS version 20.

Results: The test scores were highly significant (p=0.000) in TBL as compared to lecture group. In addition to positive significant relationship, majority of students also agreed that TBL motivated them to learn Pathology (71.72%), promoted better understanding of the subject matter (68.92%), helped to gain in depth knowledge of the subject (62.06%) and helped to remove misconceptions about the topic (65.51%). Sixty two percent students preferred TBL to didactic lectures.

Conclusion: Our study proved to have a significant impact of TBL on student test scores as compared to didactic lectures. Majority of the students were satisfied with TBL as a teaching methodology in Pathology and preferred it to didactic lectures.

Keywords: Active learning, Didactic lectures, Subject matter, Team based learning (TBL).


Competent health professionals who can integrate knowledge and apply needed skills are the need of the society1. Medical schools must be able to refine the medical expertiseso that the health professionals can perform the duties successfully and efficiently. Successful medical teaching requires that teachers are able to address learner's needs and understand the variations in learners' styles and approaches2. Teachers can accomplish these requirements while creating an optimal teaching-learning environment by utilizing a variety of teaching methods and teaching styles2. Although an array of newer instructional methodologies are available, traditional method of lectures is still the predominant mode of teaching in majority of Pakistan's medical institutions.

Lecture based instruction has been challenged over the past few decades, because of its quiescent and static form of learning3. Team learning is an approach to large-group teaching that combines the strengths of small-group interactive learning with teacher-driven content delivery4. Team based learning (TBL) is a relatively newer instructional strategy that has emerged over the past few years to enhance active learning and critical thinking. This method, first used in business education, was later applied to undergraduate medical education and postgraduate medicine clerkship5-9. It incorporates the strengths of small group learning in a large group setup10. TBL is a structured form of cooperative learning a form of active learning in which small groups of students work together on an issue11. Thus proper planning, timely and active feedback to students is the key to a successful TBL12.

TBL provides opportunities to the team members to develop cooperative thinking at the same time improving social and communication skills11. The aim of TBL is to achieve higher levels of cognitive learning using personal knowledge within a collaborative environment11.

The beneficial effects of TBL on student learning are quite evident from literature. However, effect on assessment scores is a major concern for all stakeholders while adopting a new teaching methodology13. Moreover, satisfaction of students regarding a teaching methodology is also fundamental to its successful implementation14. Therefore we planned to study the effect of TBL on student`s test scores and to determine the level of student satisfaction with this methodology.


A quasi experimental study was conducted with fourth year undergraduate female medical students (strength 98) attending a course on haematologyat University Medical and Dental College (UMDC) Faisalabad, Pakistan, from January to March 2013. UMDC follows a 5 year discipline based curriculum for MBBS program. Pathology is taught in years 3 and 4 using different instructional methodssuch as lectures, tutorials and practical demonstrations, followed by assessment of each topic. Haematologyis taught in fourth year using the same teaching methods.

Prior to launching TBL, a faculty development workshop was conducted for the faculty of Pathology by the Department of Medical Education toincrease awareness regarding TBL. The subject of haematology was divided into two sections. First section (H-1) included the topics of anemia and leukemia while the second (H-2) included lymphomas and bleeding disorders. Multiple choice questions (MCQ) addressing the cognitive levels of recall C1, interpretation C2 and problem solving C3 were prepared by the faculty members according to a table of specifications14. These were then reviewed for technical appropriateness by the DME faculty and improved. For each TBL 10 MCQ's of C1 and C2 and 4 MCQ's of C3 level were selected. The C3 level MCQ's focused on higher level of cognition that could initiate a consensus building discussion. The aim was to test the understanding of the concepts rather than just memorizing the facts.

The learning outcomes and the topics along with resources such as reference books with page numbers specified and websites were displayed on the notice board 10 days before the start of the TBL. The hand-outs of the lectures on the topics were also available in the library in case the students were interested in using them.

Students were randomly assigned to a total of 14 different groups consisting of seven students each based on the roll numbers using computer software. The same groups were kept in both the sessions so that they could evolve into functioning teams over the course of time.

The content of first section of hematology (H-1) was explored in two TBL sessions of 2 hours and 15 minutes duration each (total duration 4 hours 30 minutes). The second half (H-2) was covered in 8 lectures of 45 minutes duration each (total duration 6 hours).

The students were oriented to TBL by the Principal Investigator (PI) and Co-investigator one week before starting the TBL. This was followed by a mock TBL which was duly supervised by the researchers and all queries by students addressed. The TBL session was conducted according to Lary Michaelson model12. The session started with individual readiness assurance test (iRAT), where students had to attempt a test independently comprising of 10 MCQs. This was followed by team readiness assurance test (tRAT) in which they attempted the same questions after discussion in teams. During the time the students attempted the t-RAT in groups; the facilitator marked thei-RAT and identified the questions in which majority of the students were having difficulties. The next segment was a mini lecture by the facilitator explaining those concepts where students had faced difficulty.

Table: Questionnaire to assess satisfaction of students about team based learning.



01###It motivates me to learn pathology###71.72414###7.5862069###20.689655

02###It promotes better understanding of the subject matter###68.96552###8.2758621###22.758621

03###It help to gain an in-depth knowledge about the###62.06897###13.103448###24.827586


04###TBL help to reduce my misconceptions about the topic###65.51724###10.344828###24.137931

05###TBL stimulate my thinking###67.58621###10.344828###22.068966

06###TBL improve my reasoning skills###71.72414###6.8965517###21.37931

07###This type of teaching helps me to relate pathological###62.75862###11.034483###26.206897

###principles to real life situation

08###I feel TBL and case studies should be included in###59.31034###6.2068966###34.482759

###pathology curriculum

09###I prefer this type of teaching to didactic lectures###62.06897###8.9655172###28.965517

10###It helps to improve team working skills###73.10345###7.5862069###19.310345

After this discussion the teams were given four MCQs of C3 levelto be solved in 10 minutes. Students showed their answers simultaneously by raising cards with the alphabet of the option selected. The facilitator then discussed the case with all students discussing each and every option. The students were also given the right to make an appeal in case there was any problem with any MCQ10.

After each TBL session, the students were given a validated questionnaire to assess their satisfaction about TBL.

After two TBL sessions on anemia and leukemia, the topics of bleeding disorders and lymphoma were covered in the form of lectures. After completion of the course, students took a written test comprising of problem based, short answerquestions (SAQ) regarding hematology, to test application of knowledge. The test comprised of two segments with questions of equal difficulty, representing the two halves of the topic.

Data Analysis

Data analysis included data of 61 students who attended all lectures and both sessions of TBL. Data of students who missed any teaching session were excluded. The data were analyzed using SPSS version 20. Descriptive statistics were used to determine frequency, percentage, mean and standard deviation of scores in H-1 and H-2 groups. These were compared by using paired sample t-test. A p-value of less than 0.05 was taken as significant.


The results are based on analysis of test scores from students who attended both TBL sessions and lectures, n=61. They were all girl students ranging in age from 21-22 years. 32 students (52.1%) of H-1 group and 28 students (46%) of H-2 group scored more than 50% marks. The test results of the students were compared with regard to TBL (mean=12.94 +- 4.65) and lectures (mean=11.65 +- 4.20) using paired sample t-test. The test scores were significantly higher (p=0.000) in TBL group as compared to lecture group (fig).

In addition to positive significant relationship with TBL, majority of students agreed that TBL motivated them to learn pathology (71.72%), promoted better understanding of the subject matter (68.92%), helped to gain in-depth knowledge of the subject (62.06%) and helped to remove misconceptions about the topic (65.51%). Sixty two percent students preferred TBL to lectures. Sixty-seven percent were of the view that it stimulated their thought process. Seventy one percent statedthat it improved their reasoning skills.

TBL also helped them to relate pathological principles to real life situation (63%) and improved team work (73%). Fifty nine percent felt that TBL and case studies needed to be included in pathology curriculum (table).


In our study the difference in scores of the material taught by TBL and the lectures was significant. This is consistent with the findings from the study by Koles, where the performance of second-year medical students over two consecutive academic years (2003-2004, 2004- 2005) at the Boonshoft School of Medicine was assessed. This study was conducted on 178 students. The knowledge of pathology-based content learned using the TBL strategy was compared with questions assessing pathology-based content learned via other methods and was found to be significant (p .001, t-test). Moreover, students whose overall academic work placed them in the lowest quartile of the class improved more from TBL than did those in the highest quartile15.

In another study by Brandler and Laser, TBL was introduced in Pathology residency training program. In this particular program four TBL sessions were held and individual and team readiness assurance tests (iRAT/tRATs) were performed. Residents scored higher on the readiness assurance tests when working in teams, demonstrating the vigor and potency of team learning and achievement16. Our study as compared to this was conducted on under graduate students but had the same result.

Nigel et al also conducted a controlled study of team-based learning for undergraduate clinical neurology education at National University of Singapore. This study compared TBL to passive learning measuring the knowledge as the primary outcome. The TBL encouraged self directed learning through the process of peer discussion and self-reflection to reinforce and retain the knowledge17. Our study aroused interest in the students and helped them to learn the subject of pathology autonomously.

In Pakistan, a study conducted at Lahore Medical and Dental College, in 2011 employing the modified TBL technique over 4 weeks showed that fourth year MBBS students test scores improved after TBL sessions were introduced in comparison to traditional didactic lecture session (p<0.001). Majority of the respondents noted that TBL session was a better learning strategy compared to lectures18. This finding correlates with our work which also showed improvement in the test results by TBL.

Considering students level of satisfaction, majority of the studentsin our study agreed that TBL motivated them to learn Pathology. This is similar to the findings from another study on first-year medical students of Chonnam National University Medical School where most students perceived TBL activities to be more engaging, effective and enjoyable than conventional didactics11. In this study the tRAT scores were significantly higher than the iRAT scores, demonstrating the effect of co-operative and group learning. In addition, TBL improved student performance, especially that of academically weaker students.

Similarly, results from a study in Iran revealed that student satisfaction from team-based learning in neurology was far higher as compared to traditional lectures19.

Another study in a neurology clerkship course in China showed that TBL created an active classroom atmosphere, enhanced learning motivation, strengthened teamwork spirit, and improved studentsability to solve real clinical problems. TBL was highly accepted by the majority of students20. A systematic review by Jalali etal concluded that most students have come to regard TBL as a more engaging, effective and enjoyable teaching method than the conventional didactic approach in medical schools. Also the students who came to sessions prepared were more engaged in this type of learning 21.


Our study proved to have a significant impact of TBL on student test scores as compared to didactic lectures. Furthermore, majority of the students were satisfied with TBL as a teaching methodology in Pathology and preferred it over didactic lectures.


This study has no conflict of interest to declare by any author.


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Publication:Pakistan Armed Forces Medical Journal
Article Type:Report
Geographic Code:9PAKI
Date:Jun 30, 2017

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