{"paper_id":"3e3d4ef1-d4da-4812-9c33-5b8dfe6b7eec","body_text":"Individual Post‑application Activity Test (iPAT) as an Additional Brief Assessment for Evaluating Student Learning in an Integrated Online TBL Setting in Pathology Course | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Individual Post‑application Activity Test (iPAT) as an Additional Brief Assessment for Evaluating Student Learning in an Integrated Online TBL Setting in Pathology Course Anastassia Kolde, Kaire Uiboleht, Anu Sarv, Ave Minajeva This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9269899/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background We applied the Integrated Online TBL (IO-TBL) model in teaching pathology because it combines the connectedness of synchronous meetings with the flexibility of asynchronous engagement, giving teams sufficient time to work through application activities. This structure enables a 1–2-week deepening of students’ knowledge and the content’s clinical relevance—an outcome that limited preparation time and the gap between theory and practice often prevent students from achieving during the readiness phase assessed by the Individual Readiness Assurance Test (iRAT). To objectively verify individual knowledge gains within this extended cycle, we introduced the Individual Post-Application Activity Test (iPAT) at the end of each IO-TBL module to provide validated feedback on how well core concepts are understood. This study examines how adding the iPAT, or modifying its grading weight, relates to overall performance by testing whether iPAT scores correlate with the Module Summative Test (MST) and whether this association persists after adjusting for iRAT performance. Methods A retrospective, quasi-experimental design across two academic years included 297 preclinical medical students. In the second year, the grading weight of iPAT was increased while other course elements remained unchanged. Associations were analysed using linear mixed-effects models, and student perceptions were explored through anonymous feedback. Results iPAT scores were positively associated with MST performance (β = 0.64, p < 0.001), independent of iRAT results. Increasing the weighting of iPAT strengthened this association. Students reported that iPAT supported engagement and provided a more objective measure of individual contribution than peer assessment, within TBL. Conclusions The integration of iPAT at the conclusion of every IO-TBL module serves as a focused assessment tool, delivering immediate feedback and supporting knowledge retention. Its role in verifying conceptual understanding, combined with its positive and independent link to MST performance, underscores its importance as an effective complement to traditional TBL activities. Trial registration Ethics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu, in accordance with the Declaration of Helsinki). Team-Based Learning individual learning outcome post-application activity test student assessment module summative test Figures Figure 1 Figure 2 Background Team-Based Learning (TBL) is a structured, learner-cantered instructional strategy that promotes deep learning in pre-clinical medical education through a repeated sequence of individual and collaborative activities [ 1 ]. While teamwork is central to TBL, assessing individual knowledge development through application remains essential [ 2 , 3 ]. Traditional classroom-based TBL typically assumes that students achieve substantial theoretical mastery during a pre-class preparation phase. However, in complex pre-clinical subjects like pathology, time constraints and the gap between theory and clinical practice often make full mastery prior to the session unrealistic. To address these challenges, integrated Online TBL (IO-TBL) offers a flexible, student-cantered approach that extends the learning process. In papers sharing preclinical teaching experience, mostly the preparatory phase of IO-TBL is independent and application activities (AA) stay synchronously time-limited [ 4 , 5 , 6 , 7 ]. In non-medical disciplines, significant advantages have been reported for implementing the IO-TBL model, particularly when extended independent time is allocated for offline AA over a period of one to three weeks. This temporal expansion is critical because it provides teams with sufficient time to coordinate and deliberate on complex problems and fosters true collaboration and consensus-building through a structured sequence [ 8 , 9 , 10 , 11 ]. Our study presents the use of the IO-TBL learning model in pathology and aims to develop a supplementary approach for providing students with additional test-validated feedback, specifically regarding their advancement in the later stages of IO-TBL. Below, we provide a brief overview of the TBL assessment principles, which consist of two key components. First, in courses using TBL, the final grade typically consists of two components: (1) TBL activities (iRAT, tRAT, AA, peer evaluation) and (2) individual performance based on traditional assessments (midterms, essays, reports, final exams) [ 2 ]. The weighting of TBL and individual performance in the final course grade varies widely (e.g., 10:90, 25:75, 40:60) and depends on institutional teaching culture, the course’s aims, and its importance within the profession and curriculum [ 2 , 12 ]. The second aspect, which our study particularly addresses, concerns the diversity of perspectives on assessing TBL tests and activities, reflecting differences in how each assessment component is intended to function within the learning process. It is recommended to assign a small proportion of points to the iRAT and tRAT [ 8 , 13 ]. The grading of AAs has been reported to have a potentially discouraging effect, as it may heighten students’ fear of making mistakes [ 13 ]. However, omitting AA scoring deprives students of immediate, objective verified feedback on whether they have identified the key conceptual elements of the task. This feedback gap is particularly relevant in IO-TBL, where extended engagement with AA is intended to support the progressive consolidation of the practical relevance of theoretical knowledge and at the same time, sufficient prior mastery of clinical concepts in iRAT can’t be expected. To mitigate this, we integrated a novel individual post-application activity test (iPAT) into the end of each IO-TBL module to provide verified feedback for both instructors and learners regarding the mastery of core concepts. Beyond its role as a performance indicator, the iPAT facilitates spaced learning and retrieval practice [ 14 ]. Consequently, it is necessary to explore how the addition of this assessment, or adjustments to its weight within the IO-TBL framework, impacts overall student performance alongside the existing iRAT. This study tests the hypothesis that if students’ knowledge levels have approached the requirements of the MST by the time of the iPAT, a correlation should be observed between the iPAT and MST scores; it further examines whether this relationship is attenuated after accounting for iRAT performance and explores whether assigning a higher grading weight to the iPAT is associated with improved MST outcomes. Methods Ethical approval Ethics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu, in accordance with the Declaration of Helsinki) was obtained to retrospectively analyse the individual test scores and anonymous feedback of third-year medical students in the pathology course at the University of Tartu across two consecutive academic years. All students were informed that their learning outcomes would be used in anonymized form for scientific research purposes. No personal data are used in the study, and therefore the consent requirements under the GDPR (EU 2016/679) do not apply, in accordance with the Estonian Personal Data Protection Act. Study design and participants This retrospective quasi-experimental study, conducted over two academic years, evaluated whether increasing the weight of iPAT scores in IO-TBL activities affected MST performance. Student feedback was collected on the modified grading scheme, which incorporated iPAT as a novel individual assessment component within the integrated online TBL structure. A total of 297 students who completed the pathology course over two consecutive academic years were included (143 in Year 1 and 154 in Year 2). Females comprised 66.4% in Year 1 and 64.0% in Year 2. Students were assigned to 22 teams in Year 1 and 23 in Year 2. To ensure heterogeneity, TBL teams of 6–7 students were formed at the start of the semester based on gender and academic performance, following recommendations from previous studies [2,12,15]. Students from the same practical groups were placed in different teams. Data on ethnic background were not available. Context of IO-TBL in Course Setting The incorporation of IO-TBL webinars followed best practices for implementing TBL within fully asynchronous and synchronous courses [3]. Figure 1 illustrates the timeline of in‑class and IO-TBL activities conducted over one course week, while a detailed overview of all weekly activities across the full semester is provided in Supplementary Material 1. The initial TBL webinar for each new topic was purposefully scheduled on Monday to prompt early‑week student engagement and sustained conceptual exploration, forming a coherent and integrated learning sequence in which continuous IO-TBL activities progressively prepare students for the weekly practical discussions on morphological changes. Following an introductory session in Week 0, six topic-based IO-TBLs of different lengths were delivered across three modules, with two sessions integrated into each module. The program was organized into three thematic modules, each comprising two IO-TBL, three practical classes, and ending with an MST (a total of 6 IO-TBL and 3 MST). Each IO-TBL required students to prepare independently by studying lecture materials and completing their iRAT online. Teams of students received tRAT questions a week before the webinar for discussion purposes, but submission and teacher feedback occurred synchronously during the webinar. Both the iRAT and tRAT consisted of 5–8 MCQs; however, while the iRAT focused on foundational concepts and basic theory, the tRAT incorporated simpler clinically-oriented tasks and more complex question types. In the AA, all students engaged with the same one to two brief published clinical case reports and responded to 10–13 guiding questions. These questions primarily encouraged the integration of pathology theory with the practical findings presented, while a few required additional reading and conceptual extension. Teams could conduct part of their preparatory work in shared online documents, but in‑person or online group discussion was mandatory and had to be documented with a photograph or screenshot appended to their submission within three days of the next webinar. Following this, the solutions of all teams became visible to the students, and they were required to reflect on and evaluate the other teams’ responses. By week’s end, each team had received the instructor’s initial feedback and was required to submit revisions by the following Wednesday. In the Monday webinar, the instructor reviewed the submitted solutions, guided the discussion, and highlighted the key concepts. After this, each IO-TBL topic concluded with a synchronous iPAT (4–6 timed MCQs, designed copy‑paste resistant). All tests were performed via Moodle, virtual learning environment used at the University of Tartu. Intervention design in the grading model As shown in Table 1, the overall total score and the TBL component comprising 11.3% of total grading score remained consistent across both years. The grading intervention focused on adjusting the iPAT weighting: in Year 1, students could earn up to 20 points for tRAT and 25 points for iPAT; in Year 2, these were modified to 10 and 35 points, respectively. The AA was evaluated on a pass/fail basis. Peer evaluations, conducted in Moodle during Weeks 4 and 12, were identical in both years; only the final evaluation contributed to the summative grade. As a potential source of bias, the MST questions were identical across both academic years; however, the TBL assignments and tests were updated annually to mitigate the risk of solution replication. Table 1. Weight of Individual Assessments and TBL Activities in the Final Grade Over Two Study Years. Activity Maximum points by activity Number of activities (identical in both years) Total score (% of final grade) Year 1 Year 2 Grading of individual assessments Maximal final score 280 (100%) MST of two topics 70 70 3 210 (75%) Average points for practical classes 5 5 3 15 (5.36%) Student Presentation 10 10 1 10 (2.8%) Total points for all TBL activities* 31.5 31.5 31.5 (11.3%) Grading of TBL activities iRAT 5 5 6 tRAT 20 10 6 Application activity Not graded, bonus points for outstanding answers. 6 iPAT 25 35 6 Peer evaluation 1 15 15 1 Formative, not included in final grade Peer evaluation 2 15 15 1 15 (5.36%) iRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. *Before calculating the final grade, the TBL points were divided by 10. Data Outcomes Test results were exported from the Moodle gradebook after the course ended. Test outcomes from TBL sessions were jointly analysed by module and compared to the corresponding MST results. Table 2 shows the sample characteristics and statistical indicators from the two study years. Table 2 . Descriptive statistics of TBL and MST by module and year (mean ± SD). Year 1 Year 2 p-value Sample characteristics Number of students 143 154 - Female, n (%) 95 (66.4) 99 (64.0) 0.7158 Number of teams 22 23 - Module 1 (TBL1 + TBL2) iRAT 8.5 ± 0.9 9.6 ± 0.6 <0.001*** tRAT 39.8 ± 0.5 19.8 ± 0.4 - iPAT 43.8 ± 5.8 67.2 ± 6.8 - MST 56.6 ± 6.0 53.7 ± 6.5 <0.001*** Module 2 (TBL3 + TBL4) iRAT 9.4 ± 0.9 9.2 ± 0.9 0.099** tRAT 38.4 ± 1.1 19.8 ± 1.4 - iPAT 40.1 ± 7.7 66.0 ± 8.1 - MST 54.7 ± 6.0 52.9 ± 6.1 0.013* Module 3 (TBL4 + TBL5) iRAT 8.5 ± 1.3 9.2 ± 1.0 <0.001*** tRAT 39.8 ± 0.5 19.6 ± 0.5 - iPAT 43.5 ± 8.5 63.8 ± 9.0 - MST 58.0 ± 6.2 55.0 ± 6.3 <0.001*** iRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. Statistical comparisons were conducted only for tests that exhibited identical scores across both years. *p < 0.05, **p < 0.01, *** p < 0.001 indicate statistically significant differences between response categories (Chi-square test of goodness-of-fit, Fisher’s exact test was used in cases where the expected cell frequency in any category was below five). Statistical analysis The iPAT score was defined as the sum of the two iPAT point scores obtained within the module. Because raw iPAT scores were on different scales across years, they were standardized within each year (z-scores) to enable comparisons across cohorts. A series of linear mixed-effects models was fitted using the lmer function from the lmerTest package in R to evaluate associations between students’ iPAT performance and MST outcomes. Each model included a random intercept for participant ID to account for repeated measures within individuals. The first model examined whether standardized individual iPAT performance was associated with MST scores. Year was included as a fixed effect to adjust for overall differences between the first and second study years, while module and sex were also included as fixed factors. The second model additionally included the iRAT score as a covariate to assess whether the association between iPAT and MST was attenuated after accounting for students’ initial readiness for the TBL session. The third model used the iPAT share , defined as the proportion of iPAT points out of the total module score (iPAT + iRAT + tRAT), to evaluate whether changes in the relative weighting of iPAT within a module were related to MST performance. An interaction term between iPAT share and year was included to test whether this association differed between cohorts. For all models, p-values were obtained using Satterthwaite’s approximation as implemented in lmerTest . For comparisons involving continuous variables, Welch’s t-test was used, whereas for categorical variables, differences in observed counts were assessed using the Chi-square test of goodness-of-fit. Fisher’s exact test was applied when the expected cell frequency in any category was below five. The association between each student’s iRAT and iPAT scores was additionally evaluated using Spearman’s rank correlation. All analyses were performed using R version 4.2.2, and the statistical significance level was set at 0.05. Results Relationship between iPAT and MST scores over two study years Analysis of the relationship between individual iPAT performance (Figure 2.A) and MST outcomes revealed that a higher standardized iPAT performance (z-score) associated positively with MST score (β = 0.64, p < .001) across modules, indicating that a one-standard-deviation increase in iPAT score corresponded to a 0.64-point increase in the MST result. All test scores were lower in Module 2 (β = –1.09, p = .0016) and higher in Module 3 (β = 1.54, p < .001) compared to Module 1. No significant differences were observed by sex. The adjusted MST level in Year 2 was lower than in Year 1 (β = –2.49, p < .001). The standard deviation of the random intercept for participants was 4.52, and the residual standard deviation was 4.13, indicating that variation in test scores occurred both between and within individuals. To assess whether the association between iPAT and MST was attenuated after accounting for iRAT performance, the iRAT score was added to the model as a covariate. Both iPAT and iRAT remained positively associated with MST outcome (β = 0.64, p < .001, and β = 0.35, p = 0.048, respectively). The coefficient for iPAT changed minimally after adjustment, indicating that the relationship between iPAT and MST cannot be fully explained by students’ prior readiness as captured by iRAT. Test scores again differed by module (lower in Module 2 and higher in Module 3) and by study year (lower in Year 2), whereas no significant differences were observed based on sex. The participant-level random intercept standard deviation (4.42) and residual standard deviation (4.16) were comparable to the previous model, confirming that substantial variation in MST performance existed both within and between individuals. In the third model (Figure 2.B), the main effect of iPAT share was not significant in Year 1 (β = 7.63, p = 0.16), but the interaction with year suggested a stronger association in Year 2 (interaction β = 17.8, p = 0.063). Based on these estimates, a 10-percentage point increase in iPAT share (e.g., from 0.4 to 0.5) in Year 2 was associated with an estimated 2.5-point increase in the MST scores. As the interaction did not meet the conventional significance threshold, the result is consistent with a stronger relationship between iPAT share and MST performance in the cohort with a higher iPAT grading emphasis. The participant-level random intercept standard deviation was 4.63, again comparable to the residual standard deviation (4.09), reflecting both within- and between-person variation in test scores. When analysing the paired individual test scores, we consistently observed a weak Spearman correlation (ρ ≈ 0.12) between students’ iRAT and iPAT results across both academic years. This means the iRAT scores accounted for only approximately 1–2% of the variance observed in iPAT scores. Student Feedback Anonymous student feedback was collected in Moodle at the end of the second year. The questions and response statistics from these 77 respondents are summarized in Table 3. According to feedback, iRAT (44.2%) and iPAT (41.6%) were perceived as the most difficult TBL tests, whereas tRAT (14.3%) was perceived significantly easier (p < .001). Conversely, tRAT was most frequently identified as the easiest test (50.7%), followed by iPAT (27.3%) and iRAT (22.1%) (p < 0.01). The presence of iPAT at the end of each topic motivated 63.7% of students to engage more deeply with the material (p < .001). Regarding workload, 55.9% felt there were ‘too many’ or ‘rather too many’ tests, while 43.0% found the number appropriate (p < .001). Finally, 61.0% considered iPAT a more objective method for evaluating participation than peer assessment (39.0%) (p = 0.053). Table 3. Student feedback in Year 2. Questions % of answers p-value Which of the TBL tests felt the most difficult for you? Answers ranked by difficulty: 0.0018* iRAT 44.2 iPAT 41.6 tRAT 14.3 Which of the TBL tests felt the easiest for you? Answers ranked by simplicity: 0.0047* tRAT 50.7 iPAT 27.3 iRAT 22.1 To what extent did knowing that the iPAT would take place at the end of each TBL topic motivate you to engage more with the materials? 2.9 × 10⁻⁸ *** Very significantly. 9.1 Rather more. 54.6 Rather less. 20.8 Not at all. 15.6 How did you feel about the number of tests/assignments in the TBL seminars? 6.2 × 10⁻¹³ *** Too many. 16.9 Rather too many. 39.0 Just the right number. 43.0 Rather too few. 0.0 Too few. 1.3 What is the most objective method for assessing participation in solving a situational task in TBL? 0.053 iPAT 61.0 Student peer evaluation 39.0 iRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. *p < 0.05, **p < 0.01, *** p < 0.001 indicate statistically significant differences between response categories (Chi-square test of goodness-of-fit, Fisher’s exact test was used in cases where the expected cell frequency in any category was below five). Statistical comparisons were conducted only where the same scoring system was used for both years. N=77. Discussion IO‑TBL was incorporated into preclinical pathology course to prompt early‑week engagement with each new topic and to provide a continuous learning thread throughout the week, enabling students to build progressively deeper clinical understanding through both the TBL AA work and the weekly practical sessions on morphological changes. Although iRAT is traditionally viewed as a key accountability measure [12], in an online setting, and the limited time between topics, iRAT can primarily assess only foundational concepts and core theory. The practical application and full pedagogical significance are expected to develop only over the 1–2‑week IO‑TBL, as in the process of AA, the students review the materials and engage in progressively deeper reflection. One challenge of IO‑TBL is that learners may not receive sufficiently early individual feedback on the development of their understanding of course content, and although our study incorporated several previously described formative feedback mechanisms—such as reflecting on and evaluating other teams’ responses, submitting written revisions when prompted by the instructor’s initial feedback, and receiving a synchronous explanatory overview during a follow‑up webinar [8, 9, 10, 11]—it still lacked an objective, test‑verified method to determine how thoroughly each medical student had grasped the essential clinical application of the underlying theory or meaningfully engaged in the learning process. To address this limitation, an additional synchronous assessment activity, the iPAT, was added to the TBL framework. In addition to the feedback provided to both students and instructors on the development of students’ individual understanding of the AA, the iPAT is intended to support the retrieval practice of previously learned material [16] and can also be viewed as evidence of meaningful engagement in an online setting. The main finding of the study is that when each TBL seminar concluded with an iPAT, its results correlated with MST performance, particularly in Year 2 when the weight of iPAT points was increased. Awareness that conceptual understanding would be assessed by a test at the end of each TBL module enhances students’ commitment to engaging more deeply with the AA. Importantly, the positive effect of iPAT on MST scores remained even after adjusting for iRAT performance, indicating that the iPAT effect was independent of prior readiness. Positive association between the iPAT and MST scores confirm our hypothesis that students attained a deeper and more integrated understanding by the end of the IO‑TBL module, surpassing the initial knowledge level captured by the iRAT and aligning more closely with MST expectations. This is further supported by a consistently weak correlation between students’ iRAT and iPAT scores across both academic years. Thus, the two individual tests in our IO-TBL model measure different cognitive processes: iRAT captures early understanding, but iPAT reflects knowledge consolidation and deeper reflection. This suggests the students who begin with lower iRAT scores can catch up by the time they take the iPAT, and that iPAT performance reflects later-stage deeper learning in the IO‑TBL model. Integrating iPAT into TBL enhances student learning in three keyways. First, iPAT provides students with immediate feedback following the AA, enabling them to refine their learning strategies for the subsequent week’s topic. Second, while the primary purpose of the AA is to apply core concepts to real-life cases, learners may still develop fragmented or inconsistent conceptual understanding. In this context, iPAT serves to assess the most critical conceptual elements, thereby helping students align their understanding with the intended learning outcomes. Third, consistent and frequent testing promotes retrieval practice and helps mitigate knowledge decay, as demonstrated in previous research [16]. The students perceived that the iPAT test was as difficult as the iRAT, yet more than half agreed that it motivated deeper learning and provided a more objective method for evaluating their contribution to IO-TBL compared with peer evaluation. Peer evaluation, which is typically conducted once or twice per course, and evaluates contributions to team activities rather than individual mastery of core concepts [1, 17, 18]. Substituting the iPAT with assessment of the AA would be pedagogically inappropriate, as evaluating the AA tends to provoke anxiety about errors and may undermine the exploratory nature of the learning process [12,15,19]; moreover, the assessment itself is frequently challenging to perform objectively. The limitation of this study is lower test scores in Year 2 may reflect either cohort-specific differences or shifts in instructional or assessment practices, making it difficult to attribute the observed performance changes to a single cause. Conclusions and practical implications The integration of an iPAT at the end of each IO‑TBL module provides a focused assessment that delivers immediate feedback and reinforces learning derived from the application activity, independent of the readiness‑assurance process (iRAT). By confirming conceptual understanding and demonstrating a clear, standalone association with MST performance, the iPAT functions as an important complement to traditional TBL components. Unlike the preparatory iRAT taken at the beginning of the module, the iPAT differs in both content and cognitive depth, as it assesses the development of learners’ later, deeper conceptual understanding. Its inclusion becomes particularly critical when the content or timing of a module constrains what the iRAT can accomplish in fostering a comprehensive practical understanding. Although students perceive the iPAT to be as challenging as the iRAT, they agree that it motivates deeper learning and provides a more objective means of evaluating their contribution to TBL compared with peer assessment. In IO‑TBL modules lasting one to three weeks, the use of an end‑of‑module iPAT is therefore justified, as it provides objective insight into how students’ practical and conceptual understanding evolves over the course of the module. In settings where students work with high autonomy on the AA—potentially with support from artificial intelligence—and instructor oversight is limited or the AA is not graded, the iPAT offers a valuable source of feedback and an effective measure of meaningful engagement, broadening its relevance across diverse disciplines. Abbreviations AA Application Activity IO-TBL Integrated online team‑based learning iRAT Individual Readiness Assurance Test iPAT Individual Post-application Activity Test MST module summative test tRAT Team Readiness Assurance Test TBL Team‑Based Learning Declarations Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Acknowledgments The authors gratefully acknowledge Miriam A. Hickey for her thorough review and valuable feedback on the manuscript. Ethics statement Ethics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu). All student personal data were anonymized before including into analysis. Competing Interests/Disclosure statement No potential conflict of interest relevant to this article was reported. Funding None. Consent for Publication Not applicable. Author’s Contributions AK, KU, AS, and AM contributed to the conceptualization of the study. AK and AM were responsible for data curation. AK, KU, and AS conducted the methodology development, formal analysis, and validation. AM managed project administration. The original draft of the manuscript was prepared by AK, KU, and AM , and all authors ( AK, KU, AS, and AM ) contributed to manuscript review and editing. All authors approved the final version of the manuscript. Authors Ave Minajeva is an Associate Professor of Pathology at the University of Tartu, who was the first to successfully introduce the TBL teaching format into pathology course in Estonia. With seven years of experience in implementing TBL, she has gained deep insight into its strengths and limitations. During this process, it became evident that TBL required certain enhancements which the authors wish to share. Anastassia Kolde is a Research Fellow and Lecturer in Mathematical Statistics at the University of Tartu, who has also begun implementing TBL in her courses and contributed to the statistical analysis for this article. Kaire Uiboleht and Anu Sarv are learning skills consultants at the University of Tartu, whose guidance and support—both in daily work and in the preparation of this article—have been invaluable. ORCID Anastassia Kolde: https://orcid.org/0009-0002-6963-7053; Kaire Uiboleht: https://orcid.org/0000-0002-8066-5904; Anu Sarv: https://orcid.org/0009-0009-6945-9593; Ave Minajeva: https://orcid.org/0000-0003-0256-1410 References Ahmad-Naik D, Webb A, Namboothiri VK, Valter K. The practices and strategies for implementing team-based learning in pre-clinical medical education: a systematic review. BMC Med Educ. 2026 Feb;11. 10.1186/s12909-026-08713-x . Sibley J, Ostafichuk P. Getting started with team-based learning. Taylor & Francis; 2023. 10.4324/9781003445012 . 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Supplementary Files SupplementaryMaterialfile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 14 May, 2026 Reviewers agreed at journal 06 May, 2026 Reviewers invited by journal 06 May, 2026 Editor assigned by journal 04 May, 2026 Editor invited by journal 07 Apr, 2026 Submission checks completed at journal 06 Apr, 2026 First submitted to journal 06 Apr, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9269899\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":639905621,\"identity\":\"64d33320-b292-4bc4-99c2-598f8773117a\",\"order_by\":0,\"name\":\"Anastassia Kolde\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Tartu\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anastassia\",\"middleName\":\"\",\"lastName\":\"Kolde\",\"suffix\":\"\"},{\"id\":639905630,\"identity\":\"6c611996-0647-4207-b61a-2fa6785d6b9e\",\"order_by\":1,\"name\":\"Kaire Uiboleht\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Tartu\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Kaire\",\"middleName\":\"\",\"lastName\":\"Uiboleht\",\"suffix\":\"\"},{\"id\":639905641,\"identity\":\"1c9af5d8-1b76-46a5-9fda-08b8edc787d8\",\"order_by\":2,\"name\":\"Anu Sarv\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"University of Tartu\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Anu\",\"middleName\":\"\",\"lastName\":\"Sarv\",\"suffix\":\"\"},{\"id\":639905652,\"identity\":\"30869a6a-4ec7-4885-b480-cbb7637547d5\",\"order_by\":3,\"name\":\"Ave Minajeva\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA1UlEQVRIiWNgGAWjYNACAwYGxgYg/YFkLYwzQCySADMPMVr4ZyQfYLpRcEeeub3H8LNt2x8GfvYG/FokbqQlMOcYPDNs7DljLJ3bZsAg2XOAgDVnzhgAtRxmbJyRlgDWYnAjAb8O+TPnP4C02DfOf5b82xKoxf7+A/xaDI73MIC0JDbOYD4mzQiyRYKAuwyPtxkcBmpJbuxJPmbZc86YR+IMAYfJHWZ++Djnz2Hbje0Hm2/8KJOT428/QMAaIAArMWyAcHgIq4cBeeKVjoJRMApGwUgDAAEJQyEWm3ZcAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"University of Tartu\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Ave\",\"middleName\":\"\",\"lastName\":\"Minajeva\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-30 16:38:56\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9269899/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9269899/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":109265467,\"identity\":\"850e64d7-01e9-4c37-b851-12c7c5497a8b\",\"added_by\":\"auto\",\"created_at\":\"2026-05-14 12:27:45\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":109825,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eOverview of one course week with IO-TBL model\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9269899/v1/6c2916c96963448fb8f9422c.jpeg\"},{\"id\":109296235,\"identity\":\"bddcbf13-5f7d-4b81-962d-0920b955bb8d\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 08:46:18\",\"extension\":\"png\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":25810,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003ePredicted module summative test (MST) scores by (A) standardized iPAT scores and (B) iPAT weighting in total TBL grading. Lines represent model-predicted values with 95 % confidence intervals from linear mixed-effects models adjusted for module, sex, and year.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Onlinefloatimage2.png\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9269899/v1/cb87f2308f48e29bafc0ea25.png\"},{\"id\":109297305,\"identity\":\"3c18e04c-d3f7-4e81-a7ce-7cd42e6e0147\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 08:55:55\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":433433,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9269899/v1/cd3f1936-0e2e-46e4-ac58-73ec7d061bc1.pdf\"},{\"id\":109296261,\"identity\":\"ab7dfa2d-8df4-4447-b16e-87c8090e5f40\",\"added_by\":\"auto\",\"created_at\":\"2026-05-15 08:46:24\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":34498,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryMaterialfile1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9269899/v1/e62f2784261a8727e48adaed.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Individual Post‑application Activity Test (iPAT) as an Additional Brief Assessment for Evaluating Student Learning in an Integrated Online TBL Setting in Pathology Course\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eTeam-Based Learning (TBL) is a structured, learner-cantered instructional strategy that promotes deep learning in pre-clinical medical education through a repeated sequence of individual and collaborative activities [\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]. While teamwork is central to TBL, assessing individual knowledge development through application remains essential [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]. Traditional classroom-based TBL typically assumes that students achieve substantial theoretical mastery during a pre-class preparation phase. However, in complex pre-clinical subjects like pathology, time constraints and the gap between theory and clinical practice often make full mastery prior to the session unrealistic. To address these challenges, integrated Online TBL (IO-TBL) offers a flexible, student-cantered approach that extends the learning process.\\u003c/p\\u003e \\u003cp\\u003eIn papers sharing preclinical teaching experience, mostly the preparatory phase of IO-TBL is independent and application activities (AA) stay synchronously time-limited [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]. In non-medical disciplines, significant advantages have been reported for implementing the IO-TBL model, particularly when extended independent time is allocated for offline AA over a period of one to three weeks. This temporal expansion is critical because it provides teams with sufficient time to coordinate and deliberate on complex problems and fosters true collaboration and consensus-building through a structured sequence [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eOur study presents the use of the IO-TBL learning model in pathology and aims to develop a supplementary approach for providing students with additional test-validated feedback, specifically regarding their advancement in the later stages of IO-TBL. Below, we provide a brief overview of the TBL assessment principles, which consist of two key components. First, in courses using TBL, the final grade typically consists of two components: (1) TBL activities (iRAT, tRAT, AA, peer evaluation) and (2) individual performance based on traditional assessments (midterms, essays, reports, final exams) [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. The weighting of TBL and individual performance in the final course grade varies widely (e.g., 10:90, 25:75, 40:60) and depends on institutional teaching culture, the course\\u0026rsquo;s aims, and its importance within the profession and curriculum [\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe second aspect, which our study particularly addresses, concerns the diversity of perspectives on assessing TBL tests and activities, reflecting differences in how each assessment component is intended to function within the learning process. It is recommended to assign a small proportion of points to the iRAT and tRAT [\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. The grading of AAs has been reported to have a potentially discouraging effect, as it may heighten students\\u0026rsquo; fear of making mistakes [\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]. However, omitting AA scoring deprives students of immediate, objective verified feedback on whether they have identified the key conceptual elements of the task. This feedback gap is particularly relevant in IO-TBL, where extended engagement with AA is intended to support the progressive consolidation of the practical relevance of theoretical knowledge and at the same time, sufficient prior mastery of clinical concepts in iRAT can\\u0026rsquo;t be expected.\\u003c/p\\u003e \\u003cp\\u003eTo mitigate this, we integrated a novel individual post-application activity test (iPAT) into the end of each IO-TBL module to provide verified feedback for both instructors and learners regarding the mastery of core concepts. Beyond its role as a performance indicator, the iPAT facilitates spaced learning and retrieval practice [\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]. Consequently, it is necessary to explore how the addition of this assessment, or adjustments to its weight within the IO-TBL framework, impacts overall student performance alongside the existing iRAT.\\u003c/p\\u003e \\u003cp\\u003eThis study tests the hypothesis that if students\\u0026rsquo; knowledge levels have approached the requirements of the MST by the time of the iPAT, a correlation should be observed between the iPAT and MST scores; it further examines whether this relationship is attenuated after accounting for iRAT performance and explores whether assigning a higher grading weight to the iPAT is associated with improved MST outcomes.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003ch2\\u003eEthical approval\\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003eEthics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu, in accordance with the Declaration of Helsinki) was obtained to retrospectively analyse the individual test scores and anonymous feedback of third-year medical students in the pathology course at the University of Tartu across two consecutive academic years. All students were informed that their learning outcomes would be used in anonymized form for scientific research purposes. No personal data are used in the study, and therefore the consent requirements under the GDPR (EU 2016/679) do not apply, in accordance with the Estonian Personal Data Protection Act.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eStudy design\\u0026nbsp;and participants\\u003c/h2\\u003e\\n\\u003cp\\u003eThis retrospective quasi-experimental study, conducted over two academic years, evaluated whether increasing the weight of iPAT scores in IO-TBL activities affected MST performance. Student feedback was collected on the modified grading scheme, which incorporated iPAT as a novel individual assessment component within the integrated online TBL structure.\\u003c/p\\u003e\\n\\u003cp\\u003eA total of 297 students who completed the pathology course over two consecutive academic years were included (143 in Year 1 and 154 in Year 2). Females comprised 66.4% in Year 1 and 64.0% in Year 2. Students were assigned to 22 teams in Year 1 and 23 in Year 2. To ensure heterogeneity, TBL teams of 6\\u0026ndash;7 students were formed at the start of the semester based on gender and academic performance, following recommendations from previous studies\\u0026nbsp;[2,12,15].\\u0026nbsp;Students from the same practical groups were placed in different teams. Data on ethnic background were not available.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eContext of IO-TBL in Course Setting\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe incorporation of IO-TBL webinars followed best practices for implementing TBL within fully asynchronous and synchronous courses [3]. \\u0026nbsp;Figure 1 illustrates the timeline of in‑class and IO-TBL activities conducted over one course week, while a detailed overview of all weekly activities across the full semester is provided in Supplementary Material 1. The initial TBL webinar for each new topic was purposefully scheduled on Monday to prompt early‑week student engagement and sustained conceptual exploration, forming a coherent and integrated learning sequence in which continuous IO-TBL activities progressively prepare students for the weekly practical discussions on morphological changes.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eFollowing an introductory session in Week 0, six topic-based IO-TBLs of different lengths were delivered across three modules, with two sessions integrated into each module. The program was organized into three thematic modules, each comprising two IO-TBL, three practical classes, and ending with an MST (a total of 6 IO-TBL and 3 MST).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eEach IO-TBL required students to prepare independently by studying lecture materials and completing their iRAT online. Teams of students received tRAT questions a week before the webinar for discussion purposes, but submission and teacher feedback occurred synchronously during the webinar. Both the iRAT and tRAT consisted of 5\\u0026ndash;8 MCQs; however, while the iRAT focused on foundational concepts and basic theory, the tRAT incorporated simpler clinically-oriented tasks and more complex question types. In the AA, all students engaged with the same one to two brief published clinical case reports and responded to 10\\u0026ndash;13 guiding questions. These questions primarily encouraged the integration of pathology theory with the practical findings presented, while a few required additional reading and conceptual extension. Teams could conduct part of their preparatory work in shared online documents, but in‑person or online group discussion was mandatory and had to be documented with a photograph or screenshot appended to their submission within three days of the next webinar. Following this, the solutions of all teams became visible to the students, and they were required to reflect on and evaluate the other teams\\u0026rsquo; responses. By week\\u0026rsquo;s end, each team had received the instructor\\u0026rsquo;s initial feedback and was required to submit revisions by the following Wednesday. In the Monday webinar, the instructor reviewed the submitted solutions, guided the discussion, and highlighted the key concepts. After this, each IO-TBL topic concluded with a synchronous iPAT (4\\u0026ndash;6 timed MCQs, designed copy‑paste resistant). All tests were performed via Moodle, virtual learning environment used at the University of Tartu. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eIntervention design in the grading model\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAs shown in Table 1, the overall total score and the TBL component comprising 11.3% of total grading score remained consistent across both years. The grading intervention focused on adjusting the iPAT weighting: in Year 1, students could earn up to 20 points for tRAT and 25 points for iPAT; in Year 2, these were modified to 10 and 35 points, respectively. The AA was evaluated on a pass/fail basis. Peer evaluations, conducted in Moodle during Weeks 4 and 12, were identical in both years; only the final evaluation contributed to the summative grade.\\u003c/p\\u003e\\n\\u003cp\\u003eAs a potential source of bias, the MST questions were identical across both academic years; however, the TBL assignments and tests were updated annually to mitigate the risk of solution replication.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 1.\\u003c/strong\\u003e Weight of Individual Assessments and TBL Activities in the Final Grade Over Two Study Years.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"491\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eActivity\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMaximum points by activity\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eNumber of activities\\u003c/strong\\u003e (identical in both years)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal score\\u0026nbsp;\\u003c/strong\\u003e\\u003cem\\u003e\\u0026nbsp;(% of final grade)\\u003c/em\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eYear 1\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eYear 2\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003e\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" valign=\\\"top\\\" style=\\\"width: 491px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eGrading of individual assessments\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eMaximal final score\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e280 (100%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eMST of two topics\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e70\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e210 (75%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eAverage points for practical classes\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e15 (5.36%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eStudent Presentation\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e10 (2.8%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" valign=\\\"top\\\" style=\\\"width: 491px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eTotal points for all TBL activities*\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e31.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e31.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e31.5 (11.3%)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd colspan=\\\"5\\\" valign=\\\"top\\\" style=\\\"width: 491px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eGrading of TBL activities\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eiRAT\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003etRAT\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e20\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e10\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eApplication activity\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd colspan=\\\"2\\\" valign=\\\"top\\\" style=\\\"width: 142px;\\\"\\u003e\\n \\u003cp\\u003eNot graded, bonus points for outstanding answers.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003eiPAT\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e25\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e35\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003ePeer evaluation 1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e15\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e15\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003eFormative, not included in final grade\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 151px;\\\"\\u003e\\n \\u003cp\\u003ePeer evaluation 2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 76px;\\\"\\u003e\\n \\u003cp\\u003e15\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e15\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 113px;\\\"\\u003e\\n \\u003cp\\u003e15 (5.36%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eiRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. *Before calculating the final grade, the TBL points were divided by 10.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData Outcomes\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eTest results were exported from the Moodle gradebook after the course ended. Test outcomes from TBL sessions were jointly analysed by module and compared to the corresponding MST results. Table 2 shows the sample characteristics and statistical indicators from the two study years.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eTable 2\\u003c/strong\\u003e. Descriptive statistics of TBL and MST by module and year (mean \\u0026plusmn; SD).\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"444\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eYear 1\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eYear 2\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eSample characteristics\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eNumber of students\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e143\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e154\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eFemale, n (%)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e95 (66.4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e99 (64.0)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e0.7158\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eNumber of teams\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e22\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e23\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eModule 1 (TBL1 + TBL2)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e8.5 \\u0026plusmn; 0.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e9.6 \\u0026plusmn; 0.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003etRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e39.8 \\u0026plusmn; 0.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e19.8 \\u0026plusmn; 0.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e43.8 \\u0026plusmn; 5.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e67.2 \\u0026plusmn; 6.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eMST\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e56.6 \\u0026plusmn; 6.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e53.7 \\u0026plusmn; 6.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eModule 2 (TBL3 + TBL4)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e9.4 \\u0026plusmn; 0.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e9.2 \\u0026plusmn; 0.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e0.099**\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003etRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e38.4 \\u0026plusmn; 1.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e19.8 \\u0026plusmn; 1.4\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e40.1 \\u0026plusmn; 7.7\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e66.0 \\u0026plusmn; 8.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eMST\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e54.7 \\u0026plusmn; 6.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e52.9 \\u0026plusmn; 6.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e0.013*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eModule 3 (TBL4 + TBL5)\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e8.5 \\u0026plusmn; 1.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e9.2 \\u0026plusmn; 1.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003etRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e39.8 \\u0026plusmn; 0.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e19.6 \\u0026plusmn; 0.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eiPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e43.5 \\u0026plusmn; 8.5\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e63.8 \\u0026plusmn; 9.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e-\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 139px;\\\"\\u003e\\n \\u003cp\\u003eMST\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 92px;\\\"\\u003e\\n \\u003cp\\u003e58.0 \\u0026plusmn; 6.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e55.0 \\u0026plusmn; 6.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 128px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026lt;0.001***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eiRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. Statistical comparisons were conducted only for tests that exhibited identical scores across both years. *p \\u0026lt; 0.05, **p \\u0026lt; 0.01, *** p \\u0026lt; 0.001 indicate statistically significant differences between response categories (Chi-square test of goodness-of-fit, Fisher\\u0026rsquo;s exact test was used in cases where the expected cell frequency in any category was below five). \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eStatistical analysis\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe iPAT score was defined as the sum of the two iPAT point scores obtained within the module. Because raw iPAT scores were on different scales across years, they were standardized within each year (z-scores) to enable comparisons across cohorts. A series of linear mixed-effects models was fitted using the lmer function from the lmerTest package in R to evaluate associations between students\\u0026rsquo; iPAT performance and MST outcomes. Each model included a random intercept for participant ID to account for repeated measures within individuals. The first model examined whether standardized individual iPAT performance was associated with MST scores. Year was included as a fixed effect to adjust for overall differences between the first and second study years, while module and sex were also included as fixed factors. The second model additionally included the iRAT score as a covariate to assess whether the association between iPAT and MST was attenuated after accounting for students\\u0026rsquo; initial readiness for the TBL session. The third model used the \\u003cem\\u003eiPAT share\\u003c/em\\u003e, defined as the proportion of iPAT points out of the total module score (iPAT + iRAT + tRAT), to evaluate whether changes in the relative weighting of iPAT within a module were related to MST performance. An interaction term between iPAT share and year was included to test whether this association differed between cohorts. For all models, p-values were obtained using Satterthwaite\\u0026rsquo;s approximation as implemented in \\u003cem\\u003elmerTest\\u003c/em\\u003e. For comparisons involving continuous variables, Welch\\u0026rsquo;s t-test was used, whereas for categorical variables, differences in observed counts were assessed using the Chi-square test of goodness-of-fit. Fisher\\u0026rsquo;s exact test was applied when the expected cell frequency in any category was below five.\\u0026nbsp;The association between each student\\u0026rsquo;s iRAT and iPAT scores was additionally evaluated using Spearman\\u0026rsquo;s rank correlation.\\u003c/p\\u003e\\n\\u003cp\\u003eAll analyses were performed using R version 4.2.2, and the statistical significance level was set at 0.05.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003ch2\\u003eRelationship between iPAT and MST scores over two study years\\u003c/h2\\u003e\\n\\u003cp\\u003eAnalysis of the relationship between individual iPAT performance (Figure 2.A) and MST outcomes revealed that a higher standardized iPAT performance (z-score) associated positively with MST score (\\u0026beta; = 0.64, p \\u0026lt; .001) across modules, indicating that a one-standard-deviation increase in iPAT score corresponded to a 0.64-point increase in the MST result. All test scores were lower in Module 2 (\\u0026beta; = \\u0026ndash;1.09, p = .0016) and higher in Module 3 (\\u0026beta; = 1.54, p \\u0026lt; .001) compared to Module 1. No significant differences were observed by sex. The adjusted MST level in Year 2 was lower than in Year 1 (\\u0026beta; = \\u0026ndash;2.49, p \\u0026lt; .001). The standard deviation of the random intercept for participants was 4.52, and the residual standard deviation was 4.13, indicating that variation in test scores occurred both between and within individuals.\\u003c/p\\u003e\\n\\u003cp\\u003eTo assess whether the association between iPAT and MST was attenuated after accounting for iRAT performance, the iRAT score was added to the model as a covariate. Both iPAT and iRAT remained positively associated with MST outcome (\\u0026beta; = 0.64, p \\u0026lt; .001, and \\u0026beta; = 0.35, p = 0.048, respectively). The coefficient for iPAT changed minimally after adjustment, indicating that the relationship between iPAT and MST cannot be fully explained by students\\u0026rsquo; prior readiness as captured by iRAT. Test scores again differed by module (lower in Module 2 and higher in Module 3) and by study year (lower in Year 2), whereas no significant differences were observed based on sex. The participant-level random intercept standard deviation (4.42) and residual standard deviation (4.16) were comparable to the previous model, confirming that substantial variation in MST performance existed both within and between individuals.\\u003c/p\\u003e\\n\\u003cp\\u003eIn the third model (Figure 2.B), the main effect of iPAT share was not significant in Year 1 (\\u0026beta; = 7.63, p = 0.16), but the interaction with year suggested a stronger association in Year 2 (interaction \\u0026beta; = 17.8, p = 0.063). Based on these estimates, a 10-percentage point increase in iPAT share (e.g., from 0.4 to 0.5) in Year 2 was associated with an estimated 2.5-point increase in the MST scores. As the interaction did not meet the conventional significance threshold, the result is consistent with a stronger relationship between iPAT share and MST performance in the cohort with a higher iPAT grading emphasis. The participant-level random intercept standard deviation was 4.63, again comparable to the residual standard deviation (4.09), reflecting both within- and between-person variation in test scores.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eWhen analysing the paired individual test scores, we consistently observed a weak Spearman correlation (\\u0026rho; \\u0026asymp; 0.12) between students\\u0026rsquo; iRAT and iPAT results across both academic years. This means the iRAT scores accounted for only approximately 1\\u0026ndash;2% of the variance observed in iPAT scores.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003ch2\\u003eStudent Feedback \\u0026nbsp;\\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003eAnonymous student feedback was collected in Moodle at the end of the second year. The questions and response statistics from these 77 respondents are summarized in Table 3. According to feedback, iRAT (44.2%) and iPAT (41.6%) were perceived as the most difficult TBL tests, whereas tRAT (14.3%) was perceived significantly easier (p \\u0026lt; .001). Conversely, tRAT was most frequently identified as the easiest test (50.7%), followed by iPAT (27.3%) and iRAT (22.1%) (p \\u0026lt; 0.01). The presence of iPAT at the end of each topic motivated 63.7% of students to engage more deeply with the material (p \\u0026lt; .001). Regarding workload, 55.9% felt there were \\u0026lsquo;too many\\u0026rsquo; or \\u0026lsquo;rather too many\\u0026rsquo; tests, while 43.0% found the number appropriate (p \\u0026lt; .001). Finally, 61.0% considered iPAT a more objective method for evaluating participation than peer assessment (39.0%) (p = 0.053).\\u003c/p\\u003e\\n\\u003cp\\u003eTable 3. Student feedback in Year 2.\\u003c/p\\u003e\\n\\u003ctable border=\\\"1\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"482\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eQuestions\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e% of answers\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003ep-value\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"bottom\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003eWhich of the TBL tests felt the most difficult for you?\\u003c/p\\u003e\\n \\u003cp\\u003eAnswers ranked by difficulty:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.0018*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; iRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e44.2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; iPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e41.6\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; tRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e14.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003eWhich of the TBL tests felt the easiest for you?\\u003c/p\\u003e\\n \\u003cp\\u003eAnswers ranked by simplicity:\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.0047*\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; tRAT\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e50.7\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; iPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e27.3\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; iRAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e22.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003eTo what extent did knowing that the iPAT would take place at the end of each TBL topic motivate you to engage more with the materials?\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e2.9 \\u0026times; 10⁻⁸ ***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Very significantly.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 9.1\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Rather more.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e54.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Rather less.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e20.8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;Not at all.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e15.6\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003eHow did you feel about the number of tests/assignments in the TBL seminars?\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e6.2 \\u0026times; 10⁻\\u0026sup1;\\u0026sup3; ***\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Too many.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e16.9\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Rather too many.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e39.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Just the right number.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e43.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Rather too few.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 0.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Too few.\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; 1.3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003eWhat is the most objective method for assessing participation in solving a situational task in TBL?\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e0.053\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; iPAT\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e61.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 330px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; Student peer evaluation\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 66px;\\\"\\u003e\\n \\u003cp\\u003e39.0\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd valign=\\\"top\\\" style=\\\"width: 85px;\\\"\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003eiRAT, Individual Readiness Assurance Test; tRAT, Team Readiness Assurance Test; iPAT, Individual Post-application Activity Test; MST, module summative test. *p \\u0026lt; 0.05, **p \\u0026lt; 0.01, *** p \\u0026lt; 0.001 indicate statistically significant differences between response categories (Chi-square test of goodness-of-fit, Fisher\\u0026rsquo;s exact test was used in cases where the expected cell frequency in any category was below five). Statistical comparisons were conducted only where the same scoring system was used for both years. N=77.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eIO‑TBL was incorporated into preclinical pathology course to prompt early‑week engagement with each new topic and to provide a continuous learning thread throughout the week, enabling students to build progressively deeper clinical understanding through both the TBL AA work and the weekly practical sessions on morphological changes. Although iRAT is traditionally viewed as a key accountability measure\\u0026nbsp;[12], in an online setting, and the limited time between topics, iRAT can primarily assess only foundational concepts and core theory. The practical application and full pedagogical significance are expected to develop only over the 1\\u0026ndash;2‑week IO‑TBL, as in the process of AA, the students review the materials and engage in progressively deeper reflection.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eOne challenge of IO‑TBL is that learners may not receive sufficiently early individual feedback on the development of their understanding of course content, and although our study incorporated several previously described formative feedback mechanisms\\u0026mdash;such as reflecting on and evaluating other teams\\u0026rsquo; responses, submitting written revisions when prompted by the instructor\\u0026rsquo;s initial feedback, and receiving a synchronous explanatory overview during a follow‑up webinar\\u0026nbsp;[8, 9, 10, 11]\\u0026mdash;it still lacked an objective, test‑verified method to determine how thoroughly each medical student had grasped the essential clinical application of the underlying theory or meaningfully engaged in the learning process.\\u003c/p\\u003e\\n\\u003cp\\u003eTo address this limitation, an additional synchronous assessment activity, the iPAT, was added to the TBL framework. \\u0026nbsp;In addition to the feedback provided to both students and instructors on the development of students\\u0026rsquo; individual understanding of the AA, the iPAT is intended to support the retrieval practice of previously learned material [16] and can also be viewed as evidence of meaningful engagement in an online setting.\\u003c/p\\u003e\\n\\u003cp\\u003eThe main finding of the study is that when each TBL seminar concluded with an iPAT, its results correlated with MST performance, particularly in Year 2 when the weight of iPAT points was increased.\\u0026nbsp;Awareness that conceptual understanding would be assessed by a test at the end of each TBL module enhances students\\u0026rsquo; commitment to engaging more deeply with the AA.\\u0026nbsp;\\u0026nbsp;Importantly, the positive effect of iPAT on MST scores remained even after adjusting for iRAT performance, indicating that the iPAT effect was independent of prior readiness. \\u0026nbsp;Positive association between the iPAT and MST scores\\u0026nbsp;confirm our hypothesis that students attained a deeper and more integrated understanding by the end of the IO‑TBL module, surpassing the initial knowledge level captured by the iRAT and aligning more closely with MST expectations. This is further supported by\\u0026nbsp;a consistently weak correlation between students\\u0026rsquo; iRAT and iPAT scores across both academic years.\\u0026nbsp;Thus, the two individual tests in our IO-TBL model measure different cognitive processes: iRAT captures early understanding, but iPAT reflects knowledge consolidation and deeper reflection. \\u0026nbsp;This suggests the students who begin with lower iRAT scores can catch up by the time they take the iPAT, and that iPAT performance reflects later-stage deeper learning in the IO‑TBL model.\\u003c/p\\u003e\\n\\u003cp\\u003eIntegrating iPAT into TBL enhances student learning in three keyways. First, iPAT provides students with immediate feedback following the AA, enabling them to refine their learning strategies for the subsequent week\\u0026rsquo;s topic. Second, while the primary purpose of the AA is to apply core concepts to real-life cases, learners may still develop fragmented or inconsistent conceptual understanding. In this context, iPAT serves to assess the most critical conceptual elements, thereby helping students align their understanding with the intended learning outcomes.\\u0026nbsp;Third, consistent and frequent testing promotes retrieval practice and helps mitigate knowledge decay, as demonstrated in previous research [16].\\u003c/p\\u003e\\n\\u003cp\\u003eThe students perceived that the iPAT test was as difficult as the iRAT, yet more than half agreed that it motivated deeper learning and provided a more objective method for evaluating their contribution to IO-TBL compared with peer evaluation. Peer evaluation, which is typically conducted once or twice per course, and evaluates contributions to team activities rather than individual mastery of core concepts [1, 17, 18].\\u003c/p\\u003e\\n\\u003cp\\u003eSubstituting the iPAT with assessment of the AA would be pedagogically inappropriate, as evaluating the AA tends to provoke anxiety about errors and may undermine the exploratory nature of the learning process\\u0026nbsp;[12,15,19]; moreover, the assessment itself is frequently challenging to perform objectively.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe limitation of this study is lower test scores in Year 2 may reflect either cohort-specific differences or shifts in instructional or assessment practices, making it difficult to attribute the observed performance changes to a single cause.\\u003c/p\\u003e\"},{\"header\":\"Conclusions and practical implications\",\"content\":\"\\u003cp\\u003eThe integration of an iPAT at the end of each IO‑TBL module provides a focused assessment that delivers immediate feedback and reinforces learning derived from the application activity, independent of the readiness‑assurance process (iRAT). By confirming conceptual understanding and demonstrating a clear, standalone association with MST performance, the iPAT functions as an important complement to traditional TBL components.\\u003c/p\\u003e\\n\\u003cp\\u003eUnlike the preparatory iRAT taken at the beginning of the module, the iPAT differs in both content and cognitive depth, as it assesses the development of learners\\u0026rsquo; later, deeper conceptual understanding. Its inclusion becomes particularly critical when the content or timing of a module constrains what the iRAT can accomplish in fostering a comprehensive practical understanding.\\u003c/p\\u003e\\n\\u003cp\\u003eAlthough students perceive the iPAT to be as challenging as the iRAT, they agree that it motivates deeper learning and provides a more objective means of evaluating their contribution to TBL compared with peer assessment.\\u003c/p\\u003e\\n\\u003cp\\u003eIn IO‑TBL modules lasting one to three weeks, the use of an end‑of‑module iPAT is therefore justified, as it provides objective insight into how students\\u0026rsquo; practical and conceptual understanding evolves over the course of the module. In settings where students work with high autonomy on the AA\\u0026mdash;potentially with support from artificial intelligence\\u0026mdash;and instructor oversight is limited or the AA is not graded, the iPAT offers a valuable source of feedback and an effective measure of meaningful engagement, broadening its relevance across diverse disciplines.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eApplication Activity\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eIO-TBL\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eIntegrated online team‑based learning\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eiRAT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eIndividual Readiness Assurance Test\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eiPAT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eIndividual Post-application Activity Test\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMST\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003emodule summative test\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003etRAT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eTeam Readiness Assurance Test\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eTBL\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eTeam‑Based Learning\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003ch2\\u003eData availability\\u003c/h2\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003ch2\\u003eAcknowledgments \\u0026nbsp;\\u0026nbsp;\\u003c/h2\\u003e\\n\\u003cp\\u003eThe authors gratefully acknowledge Miriam A. Hickey for her thorough review and valuable feedback on the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthics statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu). All student personal data were anonymized before including into analysis.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting Interests/Disclosure statement\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo potential conflict of interest relevant to this article was reported.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for Publication\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor\\u0026rsquo;s Contributions\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAK, KU, AS, and AM\\u003c/strong\\u003e contributed to the conceptualization of the study. \\u003cstrong\\u003eAK and AM\\u003c/strong\\u003e were responsible for data curation. \\u003cstrong\\u003eAK, KU, and AS\\u003c/strong\\u003e conducted the methodology development, formal analysis, and validation. \\u003cstrong\\u003eAM\\u003c/strong\\u003e managed project administration. The original draft of the manuscript was prepared by \\u003cstrong\\u003eAK, KU, and AM\\u003c/strong\\u003e, and all authors (\\u003cstrong\\u003eAK, KU, AS, and AM\\u003c/strong\\u003e) contributed to manuscript review and editing. All authors approved the final version of the manuscript.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthors\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAve Minajeva is an Associate Professor of Pathology at the University of Tartu, who was the first to successfully introduce the TBL teaching format into pathology\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003ecourse\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003ein Estonia.\\u0026nbsp;\\u003c/strong\\u003eWith seven years of experience in implementing TBL, she has gained deep insight into its strengths and limitations. During this process, it became evident that TBL required certain enhancements which the authors wish to share.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAnastassia Kolde is a Research Fellow and Lecturer in Mathematical Statistics at the University of Tartu, who has also begun implementing TBL in her courses and contributed to the statistical analysis for this article.\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eKaire Uiboleht and Anu Sarv are learning skills consultants at the University of Tartu, whose guidance and support\\u0026mdash;both in daily work and in the preparation of this article\\u0026mdash;have been invaluable.\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eORCID\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAnastassia Kolde: \\u0026nbsp;https://orcid.org/0009-0002-6963-7053;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eKaire Uiboleht: https://orcid.org/0000-0002-8066-5904;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAnu Sarv: https://orcid.org/0009-0009-6945-9593;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAve Minajeva: https://orcid.org/0000-0003-0256-1410\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eAhmad-Naik D, Webb A, Namboothiri VK, Valter K. 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Korean J Med Educ. 2018;30(1):23\\u0026ndash;9. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3946/kjme.2018.78\\u003c/span\\u003e\\u003cspan address=\\\"10.3946/kjme.2018.78\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRobertson KA, Gunderman DJ, Byram JN. Formative peer evaluation instrument for a team-based learning course: Content and construct validity. Med Teach. 2025;47(5):828\\u0026ndash;34. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1080/0142159X.2024.2374511\\u003c/span\\u003e\\u003cspan address=\\\"10.1080/0142159X.2024.2374511\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eNoel ZR, Kulo V, Cestone C, Jun HJ, Sweet M, Kubitz KA, et al. Ready or not: A crossover study of (un)graded individual readiness assurance tests in team-based learning. Am J Pharm Educ. 2024;88(3):100670. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1016/j.ajpe.2024.100670\\u003c/span\\u003e\\u003cspan address=\\\"10.1016/j.ajpe.2024.100670\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Team-Based Learning, individual learning outcome, post-application activity test, student assessment, module summative test\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9269899/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9269899/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e \\u003cp\\u003eWe applied the Integrated Online TBL (IO-TBL) model in teaching pathology because it combines the connectedness of synchronous meetings with the flexibility of asynchronous engagement, giving teams sufficient time to work through application activities. This structure enables a 1\\u0026ndash;2-week deepening of students\\u0026rsquo; knowledge and the content\\u0026rsquo;s clinical relevance\\u0026mdash;an outcome that limited preparation time and the gap between theory and practice often prevent students from achieving during the readiness phase assessed by the Individual Readiness Assurance Test (iRAT). To objectively verify individual knowledge gains within this extended cycle, we introduced the Individual Post-Application Activity Test (iPAT) at the end of each IO-TBL module to provide validated feedback on how well core concepts are understood. This study examines how adding the iPAT, or modifying its grading weight, relates to overall performance by testing whether iPAT scores correlate with the Module Summative Test (MST) and whether this association persists after adjusting for iRAT performance.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA retrospective, quasi-experimental design across two academic years included 297 preclinical medical students. In the second year, the grading weight of iPAT was increased while other course elements remained unchanged. Associations were analysed using linear mixed-effects models, and student perceptions were explored through anonymous feedback.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eiPAT scores were positively associated with MST performance (β\\u0026thinsp;=\\u0026thinsp;0.64, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001), independent of iRAT results. Increasing the weighting of iPAT strengthened this association. Students reported that iPAT supported engagement and provided a more objective measure of individual contribution than peer assessment, within TBL.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e \\u003cp\\u003eThe integration of iPAT at the conclusion of every IO-TBL module serves as a focused assessment tool, delivering immediate feedback and supporting knowledge retention. Its role in verifying conceptual understanding, combined with its positive and independent link to MST performance, underscores its importance as an effective complement to traditional TBL activities.\\u003c/p\\u003e\\u003ch2\\u003eTrial registration\\u003c/h2\\u003e \\u003cp\\u003eEthics approval No. 389/T-1 (granted by the Research Ethics Committee of the University of Tartu, in accordance with the Declaration of Helsinki).\\u003c/p\\u003e\",\"manuscriptTitle\":\"Individual Post‑application Activity Test (iPAT) as an Additional Brief Assessment for Evaluating Student Learning in an Integrated Online TBL Setting in Pathology Course\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-05-14 12:27:41\",\"doi\":\"10.21203/rs.3.rs-9269899/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-14T16:56:20+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"99006052719545142481176868030720548820\",\"date\":\"2026-05-06T09:52:08+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-05-06T06:22:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-05-04T10:23:39+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2026-04-07T10:16:19+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-04-06T05:01:32+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Medical Education\",\"date\":\"2026-04-06T04:56:53+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-medical-education\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"meed\",\"sideBox\":\"Learn more about [BMC Medical Education](http://bmcmededuc.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/meed/default.aspx\",\"title\":\"BMC Medical Education\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"0097cca5-247d-400a-82af-361c67a71219\",\"owner\":[],\"postedDate\":\"May 14th, 2026\",\"published\":true,\"recentEditorialEvents\":[{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-05-14T16:56:20+00:00\",\"index\":64,\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"99006052719545142481176868030720548820\",\"date\":\"2026-05-06T09:52:08+00:00\",\"index\":42,\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"30\",\"date\":\"2026-05-06T06:22:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-05-04T10:23:39+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-05-14T12:27:41+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-05-14 12:27:41\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9269899\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9269899\",\"identity\":\"rs-9269899\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}