Comparison of problem-based and team-based learning on Chinese basic medical education for clinical medicine: a pilot study

Comparison of problem-based and team-based learning on Chinese basic medical education for clinical medicine: a pilot study | 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 Comparison of problem-based and team-based learning on Chinese basic medical education for clinical medicine: a pilot study Lixi Gan, Xiaoxin Deng, Haibin Chen, Caixia Liu, Miao Yang, Changmin Lin, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-23853/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Since being proposed half a century ago, problem-based learning (PBL) and team-based learning (TBL) have been two popular teaching approaches used in Chinese basic medical education. To compensate for the shortcomings of lecture-based learning (LBL), both PBL and TBL can greatly benefit students. This study compares the differences of PBL and TBL on active learning and final academic scores in Chinese basic medical curriculum at Shantou University Medical College (SUMC). Methods Ten Year 4 and thirteen Year 3 medical students, enrolled in 2015 and 2016 at SUMC, were selected for TBL and PBL, respectively. In the homeostasis module, a basic-medical curriculum used in China, TBL was used for Year 4 students at their 3rd year, and PBL was used for Year 3 students. Student feedback was collected through a questionnaire. Academic achievement was based on their final examination scores. Each grade used the same final examination paper, which included both memorization and clinical application questions, as students in the traditional LBL class. Quantitative data were analyzed by t- and nonparametric tests. Results All students completed the questionnaire. Most students (PBL:62%, TBL:90%) thought the teaching approach they used was good for training clinical thinking, but PBL required more time and imposed a greater study burden. However, PBL students received higher scores than LBL students for clinical application essays ( p 0.05). Conclusion Despite the differences in the culture of learning between China and the West, TBL and PBL are two popular teaching approaches among Chinese medical students. In Chinese basic medical education, PBL is more effective in training clinical thinking, while in TBL, students spend less time with problems and are helped by the professors. The relevant assessment system and teacher training system should be perfected. Internal Medicine Educational Philosophy and Theory Problem-based learning Team-based learning Basic-medical curriculum Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Following tradition, many medical colleges use a lecture-based learning (LBL) approach to teach students whereby students passively acquire knowledge. This approach lacks feedback interaction between teachers and students, and leads to low student motivation for study [ 1 ]. Over half a century ago, problem-based learning (PBL) and team-based learning (TBL) were proposed by educators [ 2 ]. PBL was first developed in 1969 [ 3 , 4 ] and has been applied in higher medical education in China since the 1980s [ 5 ]. For current innovation in Chinese basic medical education, PBL has been extensively applied as an experimental teaching method in Chinese medical education. It is now accepted worldwide that PBL can greatly benefit students, particularly for training clinical thinking, developing teamwork, increasing acquisition and retention of knowledge, enhancing subject interest, and improving the ability to learn independently [ 2 , 6 – 10 ]. However, it is a highly controversial issue whether PBL is better than LBL for acquisition of theoretical and fundamental knowledge, as based on scores in tests of basic knowledge [ 2 , 5 , 11 – 14 ]. TBL, applied in some medical colleges in China, has also been proposed as an educational approach that retains the education strengths of PBL and achieves these in a more efficient way [ 2 ]. Like PBL, TBL encourages students to work together to solve profession-related problems and promotes clinical thinking [ 2 , 15 ]. TBL has been implemented in many schools as an instructional method that makes students well-prepared for professional practice [ 16 ]. Both have become two mainstream approaches in basic-medical education [ 17 ]. Moreover, several studies have advocated combining these two approaches [ 2 , 16 ]. However, PBL is a student-centered approach and students need to generate the learning issues on their own, whereas TBL is a learner-centered, teacher-directed instructional approach and the professors or course directors determine the study content [ 16 ]. In TBL, the professor facilitates the discussion among several groups in the classroom. In PBL, one professor leads one group’s discussion in the discussion room [ 2 ]. Few articles have compared the effects of these two teaching approaches in Chinese basic-medical curriculum. For improving these two approaches for adapting to Chinese medical education, this article compared the differences between PBL and TBL, on student learning and their final academic scores, and collected the opinions of students on their basic medical curriculum for the clinical medicine program. Methods Homeostasis module In China, medical education involves a 5-year undergraduate program that includes basic medical curricula, involving information relevant to human cellular and molecular structure and function. These lessons are aimed at laying a solid foundation for clinical studies and to develop the student’s ability to apply basic knowledge to the profession. Module teaching, including the homeostasis module, has been used in Chinese basic medical education. The homeostasis module, taught in the 3 rd year, is one of the most important components of the basic medical curriculum. Students study normal physiological structure and function, pathological mechanisms, symptoms and treatments of important diseases related to the urinary system and endocrine system in this module, which contains basic knowledge of physiology, pathophysiology, pathology, pharmacology, chirurgery and internal medicine. Through studying and applying basic medical knowledge, the ability to reason medically and think clinically can be fostered and trained by linking basic-medical education with clinical medicine. Sampling and participants Problem-based learning class PBL is a student-centered learning approach. In this class, students were divided into small groups equally and randomly, containing 5-7 students per group. One professor in each group facilitated the student discussions. During the initial discussion, students were given a case, written by professors and doctors, and allowed to work together to raise problems that were professionally relevant. During individual self-study, all group members studied relevant knowledge through textbooks and up-to-date articles to solve the same problems raised by the discussions. After self-study, the group reconvened to share the information they found to solve the problem. At the end of the session, the professor gave feedback on the discussion, case and performance of each member in the class. Team-based learning class TBL is a learner-centered, teacher-directed instructional approach, in which each class contained small groups of 3-5 students. Before the class, students needed to read the relevant assignments prepared by the professors or course directors. At the beginning of class, each student was given a quiz based on required basic and clinical knowledge. After finishing, students could discuss their own answers with their teammates to reach a consensus and post the team answers. Next, the professor organized a discussion aimed at solving the controversial questions. In addition, the professor helped students to solve the remaining problems after discussion. At the conclusion of class, each student provided written feedback on the quiz, professor and teammates online to professor. Data Collection and Analysis Student questionnaire Two questionnaires, respectively related to PBL and TBL, were distributed to the ALC students after their 3 rd year, i.e. upon finishing the homeostasis module. Likert scale statements (with 5 levels, ‘strongly disagree’, ‘disagree’, ‘neutral’, ‘agree’ and ‘strongly agree’) were used to collect the students’ opinions about their experiences in PBL and TBL on their basic-medical curriculum for the clinical medicine program. Open questions were used to ask students for the best and hardest features of PBL and TBL. The questionnaire was adapted for getting student feedback about their class experiences from a questionnaire previously designed by Thompson et al. [18]. Academic scores Each grade level used the same final examination, which included questions involving memorization, such as basic knowledge questions, and clinical application, such as clinical case-analyzing questions. In the final examination for Year 4 students at their 3 rd year, there were 70 multiple-choice questions, including 52 questions testing memorization and 18 questions testing clinical application, as well as essay questions, including 3 questions testing memorization and 1 question involving clinical application. For the final examination for Year 3 students, there were 80 multiple-choice questions, 32 questions involving required memorization and 48 questions concerning clinical application, as well as 2 essay questions that concerned clinical application. Data analysis Quantitative data were statistically analyzed using IMB SPSS Statistic 20. In quantitative data, if the data were normally distributed, a t-test and mean were used. Otherwise, a nonparametric test and median were used. Ethics approval This study was approved by Shantou University Medical College. Results In total, 13/13 (100%) Year 3 ALC students completed the questionnaire about PBL, and 10/10 (100%) Year 4 ALC students completed the questionnaire about TBL. All academic scores were collected, including 137 from the Year 4 LBL class, 10 from the Year 4 ALC class, and 202 from the Year 3 LBL and 13 from the Year 3 ALC. Findings from Academic Scores Scores for the final examinations for Year 4 and Year 3 ALC students are shown in Table 1 . In all, neither Year 4 nor Year 3 students showed any significant differences for TBL or PBL compared to LBL ( p > 0.05). Similarly, when multiple-choice questions, involving memorization and clinical application, were separately analyzed, neither TBL nor PBL showed significant differences with LBL ( p > 0.05). However, regarding the four essay questions in the 2015 final examination, ALC students did not show an obvious advantage over LBL students ( p > 0.05), but in the clinical application questions, Year 3 PBL students received higher scores than LBL students ( p < 0.05) (Table 1 ). Table 1 The outcomes about final examination of Grade 2015 and 2016 2015 2016 LBL TBL P LBL PBL P Overall average 64.95 66.45 0.635 59.65 ± 10.42 63.71 ± 7.36 0.153 Accuracy of multiple-choice questions (%) Testing memorization questions 71.91 ± 0.22 70.62 ± 0.25 0.469 65.53 ± 0.22 68.97 ± 0.27 0.444 Clinical application questions 66.78 ± 0.21 70.19 ± 0.23 0.232 65.88 ± 0.19 64.73 ± 0.27 0.730 Scores of essay questions Testing memorization questions NO.1 3.30 ± 1.13 3.64 ± 1.25 0.183 - - - NO.2 3.31 ± 2.04 3.27 ± 1.85 0.903 - - - NO.3 5.10 ± 2.03 6.18 ± 2.79 0.249 - - - Clinical application questions NO.1 3.85 ± 0.65 4.18 ± 0.60 0.088 3.54 ± 1.30 4.07 ± 0.62 0.031 NO.2 - - - 3.33 ± 2.70 5.92 ± 2.89 0.002 Findings from the Questionnaire Student response to feedback in PBL and in TBL Feedback about TBL from the Year 4 ALC can be seen in Fig. 1. Feedback about PBL from the Year 3 ALC can be seen in Fig. 2. Among TBL students, 70% agreed or strongly agreed that they were “Enjoyed the discussions in TBL”, compared to 62% in PBL (Fig. 1, item 1). About learning motivation and interest, 70% of students in TBL and 92% of students in PBL agreed or strongly agreed that active learning “increases my learning motivation and interest” (Fig. 1, item 5). Both in TBL (50%) and in PBL (92%), students agreed or strongly agreed that they “liked the study goals designed in TBL/PBL” (Fig. 1, item 8) (Figs. 1 and 2). When it came to examination, the questionnaire asked the students’ opinion about the effects of TBL/PBL on their final examination. Most students did not know whether “Useful to my final examination” (TBL:60%, PBL:38%, Fig. 1, item 4). However, 69% agreed or strongly agreed that learning basic knowledge was well suited for PBL, whereas 40% thought TBL was well suited for learning basic knowledge (Fig. 1, item 2). Not only TBL (90%) but also PBL (77%) was useful for clinical thinking, such as questions of clinical application in an examination (Fig. 1, item 3). Regarding study burden, 40% of the students in TBL and 46% in PBL agreed or strongly agreed that active learning “added to my study burden” (Fig. 1, item 6). In TBL, 50% agreed or strongly agreed that the teachers were more helpful, compared with 31% in PBL (Fig. 1, item 7) (Fig. 1 and Fig. 2). Table 2 Students’ view regarding PBL and TBL features PBL TBL This approach can develop students' ability, such as critical thinking 92.31% 70.00% team-working skills 76.92% 90.00% leadership 46.15% 20.00% communication skills 84.62% 60.00% professional ability 46.15% 30.00% clinical thinking 100.00% 80.00% others 0.00% 20.00% Most useful aspects of this approach, such as developing studying interest 7.69% 20.00% getting the answers directly from the teachers 7.69% 50.00% improving ability of expression 7.69% 10.00% helping to understand professional knowledge 46.15% 20.00% developing ability of self-study 23.08% 0.00% others 7.69% 0.00% Most different aspect of this approach, such as differences between cases and contents in the book 23.08% 10.00% time limitation in the class 0.00% 40.00% time limitation in self-study 0.00% 10.00% varying quality of cases 76.92% 40.00% others 0.00% 0.00% “Analyzing, synthesizing and solving problems” is another ability that some students think can be trained by TBL. “Learning mechanism and developing clinical thinking” is another useful aspect in PBL. The students’ views on the features of PBL and TBL are shown in Table 2 . The students thought clinical thinking, critical thinking, communication skills and team-working were trained well in these two approaches, with clinical thinking ranking first in PBL and team-working first in TBL. In addition, some students (20%) considered the ability to analyze, synthesize and solve problems to be well trained through TBL. In PBL, 46.15% of students viewed that this approach was helpful for understanding professional knowledge. Some students (7.69%) also listed “Learning mechanism and developing clinical thinking” as another advantage of PBL. The cases used in class vary in quality. Those with low quality pose difficulty for study (76.92%). When it came to TBL, students reported that the instructor’s help in class was the most popular aspect (50%). Time limitation and cases with low quality were the most difficult aspects for them (40%) (Table 2 ). The questionnaire also asked for the students’ opinion about which approach they preferred to study in this module. Most students (69.23%) in PBL preferred PBL, whereas some students (30%) in TBL chose TBL (Fig. 3). Time students spent in PBL study and TBL study The time students spent preparing for TBL/PBL can be seen in Fig. 4. Most TBL students (80%) spent 1 to 3 hours preparing for each lesson, while most PBL students (76.92%) spent 4–6 hours collecting materials and preparing for each case (Fig. 4). Discussion This study compared the PBL and TBL students’ views and their academic scores in Chinese basic medical curriculum homeostasis module and observed the following differences. TBL and PBL are popular among students Although Janneke pointed out that a certain incongruity between Chinese and Western cultures, such as a traditional secondary education, a hybrid curriculum and examination content, complicates the straightforward transfer of the new teaching approaches to such cultural contexts [19], our results show both PBL and TBL were popular among students. These results are similar to a previous study showing PBL and TBL could motivate students to study. Considering the characteristics of these two approaches, we speculate that the results may be due to the following reasons. Chinese students have used the LBL teaching model for more than 10 years since their primary education, and the new teaching approaches are a novelty that has greatly stimulated students’ interest in learning [5]. Harun et al. pointed out that three components affected students’ motivation to study: the importance of the task, the student’s ability to perform the task and their emotional reactions to the task [20]. Based on these three aspects, students were no longer given lectures during TBL and PBL. On the contrary, they worked together, exchanged their opinions and solved the problems. Therefore, they have more freedom, which would add to their motivation to study [20]. Effects of TBL and PBL on learning outcomes Previous studies found that students receive higher academic scores due to these active learning approaches [5, 21]. From our questionnaire, most students did not know whether these two approaches were appropriate for passing the final examination. However, students thought that TBL/PBL was useful for basic knowledge and clinical thinking. We speculate that the results may be due to the extra textbooks and articles in these two approaches. Comparing with LBL class, students in PBL and TBL think that these two approaches requires them to read some up-to-date articles and textbooks which are not included in the final examination but can help them to learn more basic knowledge and train their clinical thinking. Contrary to foreign studies [11, 21-23], in our study neither TBL nor PBL students showed any advantages on academic test scores and memorization questions, as compared with LBL students. This could be explained by differences in higher medical education between China and the West [5]. One of the most important differences is the diversity of reference textbooks in western countries. Most Chinese medical colleges prefer to use the same books across the country, whereas medical colleges in western countries do not use uniform textbooks or standard lecture formats [5]. In this study, the TBL and PBL students used the same references as LBL students. Before the final examination, all students would have reviewed the same basic knowledge. Furthermore, some articles pointed out that the evaluation of the effectiveness of these two approaches were still unsophisticated, particularly for basic medical education [5, 24]. In medical education in China, theory courses often occupy the most teaching time, with the largest proportion of learning contents in the final examination, which cannot completely evaluate students’ learning ability in PBL and TBL [5, 24]. Therefore, a more relevant assessment system should be implemented, such as adding laboratory course examinations [5]. Although academic test scores did not show any differences with LBL, we still think that motivation, increased by PBL and TBL, can be life-long and in the long run would benefit student to future learning. Even though in TBL there were no differences from LBL, students taught by PBL received higher scores in clinical questions. Considering the differences between TBL and PBL, the following reasons may explain the results. Although TBL is an active learning approach and motivates students, it is a teacher-directed instructional approach, which means the teacher, rather than students, decides the learning content. PBL is a student-centered approach in which students generate issues according to what they do not understand [16]. In this aspect, students study and improve on an individual basis in PBL. In addition, PBL presents advantages with respect to improving student abilities in clinical thinking [6-8]. Compared with lecture notes (such as PowerPoint presentations) in the LBL and the tests designed by professors in the TBL, PBL students use clinical cases, adapted from real patients, which is closer to the clinical situation and could better train clinical thinking. The burden of TBL and PBL From the student feedback, there are no significant differences in study burden between PBL and TBL. However, we could see that students usually spent more time preparing for PBL than TBL. The characteristics of these two approaches determine these differences. Students in TBL just need to understand the assignments and textbooks, whereas in PBL students not only are required to assimilate knowledge in the textbooks, but also research information about medical situations and updated clinical principles online, which increases the student burden [16]. Furthermore, it was proposed that during PBL additional work between cases and exploration of blind methods seemed like busy work to the learners [25]. Some students in PBL, especially lowerclassmen , spend a large amount of useless time searching information blindly rather than assimilating knowledge or training abilities. Therefore, it is necessary for medical schools to implement a tailor-made courses of study for lowerclassmen to learn how to increase information retrieval effectiveness on basic medical curriculum. On the other hand, apart from developing students’ learning abilities, the case writers could give some search material clues to students in PBL to relieve some study pressure. Effect of instructors in TBL and PBL Although instructors guided the discussion in PBL, student feedback suggested professors were more helpful in TBL than in PBL, possibly because PBL is student-centered and TBL is teacher-directed, so the professor plays different roles in these two approaches [16]. In PBL, the professor encourages students to discuss topics critically and engages students to raise and solve problems. On the contrary, in TBL, the professor gives a quiz first, facilitates the discussion, and even answers the questions during the class. However, since each discussion group requires one instructor, PBL has the disadvantage of requiring a greater number of professional instructors [26, 27]. On account of limitations on instructor-conditions, teacher training is essential. Salah emphasized that effective PBL instructors required multiple skills that are positively related to their role in large group lectures, which could have implications for recruiting PBL instructors in medical programs [28]. Furthermore, peer teaching seems to be a good way to solve the shortage of teachers. Peer teaching is beneficial for not only student teachers, but also learners [29, 30]. Conclusion Even though there are differences between Chinese and Western cultures, TBL and PBL are two popular teaching approaches among Chinese medical students in the basic medical curriculum. Furthermore, the PBL teaching approach is more effective in training clinical thinking, while the TBL teaching approach does not add to the study burden of students, and the teachers in this approach play a greater role. However, for Chinese medical students to better adapt to these two teaching approaches, during study, both TBL and PBL need to be adjusted according to the actual situation. The relevant assessment system and teacher training system should be perfected. For ease students’ burden, it is necessary for medical schools to introduce the topic, such as literature searching, in the appropriate class. Study limitations Because our study was only developed at SUMC, and the selection criteria of ALC students was strict, the sample size was limited. In addition, this study was only conducted in one basic medical curriculum and did not collect feedback from PBL and TBL teachers. Therefore, further research will enlarge the sample size and collect more data not only from students, but also from teachers, to compare PBL and TBL on the basic medical curriculum. Abbreviations PBL Problem-based learning TBL Team-based learning LBL Lecture-based learning ALC Active Learning Class SUMC Shantou University Medical College Declarations Ethics approval and consent to participate This study has been approved by the Research Ethics Committee of Shantou University Medical College. All participants were informed that their participation was voluntary. The study objective was explained to all participants, which was proved by the ethics committee. All online surveys were anonymized and untraceable. No individual subject identifiers were collected. Consent for publication Informed consent for publication was obtained from all authors. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was financially supported by Ministry of Education Humanities and Social Science Project (No. 17YJA740063) and Guangdong Province Education Promotion Project (No. [2018]68) in People’s Republic of China. The funding body did not play any roles in the design of the study, collection, analysis, and interpretation of the data, and writing the manuscript. Authors’ contributions LX contributed to study design, data collection, data analysis and drafting of the manuscript. CX contributed to data analysis. XX, CM, M, HB, FF, CX contributed to study design and critical review of the manuscript. All authors read and reviewed the final version of the manuscript. All authors read and approved the final manuscript. Authors’ information LX and XX are all the undergraduate medical students of Shantou University Medical College. HB, CM, M, FF, CX are professors of Shantou University Medical College. Acknowledgements The authors would like to acknowledge and thank the students who participated in this research. We thank Stanley Lin for proofreading the article. References Letassy NA, et al. Using team-based learning in an endocrine module taught across two campuses. Am J Pharm Educ. 2008;72(5):103. Burgess A, et al. Implementation of modified team-based learning within a problem based learning medical curriculum: a focus group study. 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College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Changmin","middleName":"","lastName":"Lin","suffix":""},{"id":524624,"identity":"2e64141f-53f4-4f43-bc39-de23d3651415","order_by":7,"name":"Fenfei Gao","email":"","orcid":"","institution":"Shantou University Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fenfei","middleName":"","lastName":"Gao","suffix":""}],"badges":[],"createdAt":"2020-04-19 12:02:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-23853/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-23853/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1015326,"identity":"9e1a02bd-2651-4385-ad71-85c7c725bfae","added_by":"auto","created_at":"2020-05-01 17:00:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":65639,"visible":true,"origin":"","legend":"Feedback for the TBL in the homeostasis module.","description":"","filename":"1.PNG","url":"https://assets-eu.researchsquare.com/files/rs-23853/v1/1.PNG"},{"id":1015327,"identity":"46bb69a8-f65f-41ec-97d6-185c43676fdd","added_by":"auto","created_at":"2020-05-01 17:00:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64581,"visible":true,"origin":"","legend":"Feedback for the PBL in the homeostasis module.","description":"","filename":"2.PNG","url":"https://assets-eu.researchsquare.com/files/rs-23853/v1/2.PNG"},{"id":1015328,"identity":"6c1d6592-18eb-4c90-959f-6cfa8ca2eef2","added_by":"auto","created_at":"2020-05-01 17:00:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":38066,"visible":true,"origin":"","legend":"Student preference for study approach used in the homeostasis module.","description":"","filename":"3.PNG","url":"https://assets-eu.researchsquare.com/files/rs-23853/v1/3.PNG"},{"id":1015329,"identity":"025cb592-a7f6-4590-89f4-ab895d5d5050","added_by":"auto","created_at":"2020-05-01 17:00:49","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":34513,"visible":true,"origin":"","legend":"Time students spent on study in PBL vs. TBL in the homeostasis module.","description":"","filename":"4.PNG","url":"https://assets-eu.researchsquare.com/files/rs-23853/v1/4.PNG"},{"id":13502266,"identity":"a7c1e67a-a59c-46c0-81ef-9bd01b422bd1","added_by":"auto","created_at":"2021-09-16 23:13:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":496262,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-23853/v1/46425b55-ae2e-412c-905a-497d0f96add7.pdf"}],"financialInterests":"","formattedTitle":"Comparison of problem-based and team-based learning on Chinese basic medical education for clinical medicine: a pilot study","fulltext":[{"header":"Background","content":" \u003cp\u003eFollowing tradition, many medical colleges use a lecture-based learning (LBL) approach to teach students whereby students passively acquire knowledge. This approach lacks feedback interaction between teachers and students, and leads to low student motivation for study [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Over half a century ago, problem-based learning (PBL) and team-based learning (TBL) were proposed by educators [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. PBL was first developed in 1969 [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and has been applied in higher medical education in China since the 1980s [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. For current innovation in Chinese basic medical education, PBL has been extensively applied as an experimental teaching method in Chinese medical education. It is now accepted worldwide that PBL can greatly benefit students, particularly for training clinical thinking, developing teamwork, increasing acquisition and retention of knowledge, enhancing subject interest, and improving the ability to learn independently [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, it is a highly controversial issue whether PBL is better than LBL for acquisition of theoretical and fundamental knowledge, as based on scores in tests of basic knowledge [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTBL, applied in some medical colleges in China, has also been proposed as an educational approach that retains the education strengths of PBL and achieves these in a more efficient way [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Like PBL, TBL encourages students to work together to solve profession-related problems and promotes clinical thinking [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. TBL has been implemented in many schools as an instructional method that makes students well-prepared for professional practice [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBoth have become two mainstream approaches in basic-medical education [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Moreover, several studies have advocated combining these two approaches [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, PBL is a student-centered approach and students need to generate the learning issues on their own, whereas TBL is a learner-centered, teacher-directed instructional approach and the professors or course directors determine the study content [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In TBL, the professor facilitates the discussion among several groups in the classroom. In PBL, one professor leads one group\u0026rsquo;s discussion in the discussion room [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Few articles have compared the effects of these two teaching approaches in Chinese basic-medical curriculum. For improving these two approaches for adapting to Chinese medical education, this article compared the differences between PBL and TBL, on student learning and their final academic scores, and collected the opinions of students on their basic medical curriculum for the clinical medicine program.\u003c/p\u003e "},{"header":"Methods","content":"\u003ch2\u003eHomeostasis module\u003c/h2\u003e\n\u003cp\u003eIn China, medical education involves a 5-year undergraduate program that includes basic medical curricula, involving information relevant to human cellular and molecular structure and function. These lessons are aimed at laying a solid foundation for clinical studies and to develop the student\u0026rsquo;s ability to apply basic knowledge to the profession. Module teaching, including the homeostasis module, has been used in Chinese basic medical education. The homeostasis module, taught in the 3\u003csup\u003erd\u003c/sup\u003e year, is one of the most important components of the basic medical curriculum. Students study normal physiological structure and function, pathological mechanisms, symptoms and treatments of important diseases related to the urinary system and endocrine system in this module, which contains basic knowledge of physiology, pathophysiology, pathology, pharmacology, chirurgery and internal medicine. Through studying and applying basic medical knowledge, the ability to reason medically and think clinically can be fostered and trained by linking basic-medical education with clinical medicine.\u003c/p\u003e\n\u003ch2\u003eSampling and participants\u003c/h2\u003e\n\u003cp\u003eProblem-based learning class\u003c/p\u003e\n\u003cp\u003ePBL is a student-centered learning approach. In this class, students were divided into small groups equally and randomly, containing 5-7 students per group. One professor in each group facilitated the student discussions. During the initial discussion, students were given a case, written by professors and doctors, and allowed to work together to raise problems that were professionally relevant. During individual self-study, all group members studied relevant knowledge through textbooks and up-to-date articles to solve the same problems raised by the discussions. After self-study, the group reconvened to share the information they found to solve the problem. At the end of the session, the professor gave feedback on the discussion, case and performance of each member in the class.\u003c/p\u003e\n\u003cp\u003eTeam-based learning class\u003c/p\u003e\n\u003cp\u003eTBL is a learner-centered, teacher-directed instructional approach, in which each class contained small groups of 3-5 students. Before the class, students needed to read the relevant assignments prepared by the professors or course directors. At the beginning of class, each student was given a quiz based on required basic and clinical knowledge. After finishing, students could discuss their own answers with their teammates to reach a consensus and post the team answers. Next, the professor organized a discussion aimed at solving the controversial questions. In addition, the professor helped students to solve the remaining problems after discussion. At the conclusion of class, each student provided written feedback on the quiz, professor and teammates online to professor.\u003c/p\u003e\n\u003ch2\u003eData Collection and Analysis\u003c/h2\u003e\n\u003cp\u003eStudent questionnaire\u003c/p\u003e\n\u003cp\u003eTwo questionnaires, respectively related to PBL and TBL, were distributed to the ALC students after their 3\u003csup\u003erd\u003c/sup\u003e year, i.e. upon finishing the homeostasis module. Likert scale statements (with 5 levels, \u0026lsquo;strongly disagree\u0026rsquo;, \u0026lsquo;disagree\u0026rsquo;, \u0026lsquo;neutral\u0026rsquo;, \u0026lsquo;agree\u0026rsquo; and \u0026lsquo;strongly agree\u0026rsquo;) were used to collect the students\u0026rsquo; opinions about their experiences in PBL and TBL on their basic-medical curriculum for the clinical medicine program. Open questions were used to ask students for the best and hardest features of PBL and TBL. The questionnaire was adapted for getting student feedback about their class experiences from a questionnaire previously designed by Thompson et al. [18].\u003c/p\u003e\n\u003cp\u003eAcademic scores\u003c/p\u003e\n\u003cp\u003eEach grade level used the same final examination, which included questions involving memorization, such as basic knowledge questions, and clinical application, such as clinical case-analyzing questions. In the final examination for Year 4 students at their 3\u003csup\u003erd\u003c/sup\u003e year, there were 70 multiple-choice questions, including 52 questions testing memorization and 18 questions testing clinical application, as well as essay questions, including 3 questions testing memorization and 1 question involving clinical application. For the final examination for Year 3 students, there were 80 multiple-choice questions, 32 questions involving required memorization and 48 questions concerning clinical application, as well as 2 essay questions that concerned clinical application.\u003c/p\u003e\n\u003cp\u003eData analysis\u003c/p\u003e\n\u003cp\u003eQuantitative data were statistically analyzed using IMB SPSS Statistic 20. In quantitative data, if the data were normally distributed, a t-test and mean were used. Otherwise, a nonparametric test and median were used.\u003c/p\u003e\n\u003ch2\u003eEthics approval\u003c/h2\u003e\n\u003cp\u003eThis study was approved by Shantou University Medical College.\u003c/p\u003e\n"},{"header":"Results","content":" \u003cp\u003eIn total, 13/13 (100%) Year 3 ALC students completed the questionnaire about PBL, and 10/10 (100%) Year 4 ALC students completed the questionnaire about TBL. All academic scores were collected, including 137 from the Year 4 LBL class, 10 from the Year 4 ALC class, and 202 from the Year 3 LBL and 13 from the Year 3 ALC.\u003c/p\u003e \u003ch2\u003eFindings from Academic Scores\u003c/h2\u003e \u003cp\u003eScores for the final examinations for Year 4 and Year 3 ALC students are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. In all, neither Year 4 nor Year 3 students showed any significant differences for TBL or PBL compared to LBL (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Similarly, when multiple-choice questions, involving memorization and clinical application, were separately analyzed, neither TBL nor PBL showed significant differences with LBL (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). However, regarding the four essay questions in the 2015 final examination, ALC students did not show an obvious advantage over LBL students (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05), but in the clinical application questions, Year 3 PBL students received higher scores than LBL students (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe outcomes about final examination of Grade 2015 and 2016\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e2015\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall average\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.635\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.65\u0026thinsp;\u0026plusmn;\u0026thinsp;10.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e63.71\u0026thinsp;\u0026plusmn;\u0026thinsp;7.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAccuracy of multiple-choice questions (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTesting memorization questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71.91\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65.53\u0026thinsp;\u0026plusmn;\u0026thinsp;0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e68.97\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical application questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.232\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e64.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.730\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScores of essay questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTesting memorization questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.30\u0026thinsp;\u0026plusmn;\u0026thinsp;1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.64\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.31\u0026thinsp;\u0026plusmn;\u0026thinsp;2.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.27\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.10\u0026thinsp;\u0026plusmn;\u0026thinsp;2.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.18\u0026thinsp;\u0026plusmn;\u0026thinsp;2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.249\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical application questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.85\u0026thinsp;\u0026plusmn;\u0026thinsp;0.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNO.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5.92\u0026thinsp;\u0026plusmn;\u0026thinsp;2.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003ch2\u003eFindings from the Questionnaire\u003c/h2\u003e \u003cp\u003eStudent response to feedback in PBL and in TBL\u003c/b\u003e \u003cp\u003eFeedback about TBL from the Year 4 ALC can be seen in Fig.\u0026nbsp;1. Feedback about PBL from the Year 3 ALC can be seen in Fig.\u0026nbsp;2. Among TBL students, 70% agreed or strongly agreed that they were \u0026ldquo;Enjoyed the discussions in TBL\u0026rdquo;, compared to 62% in PBL (Fig.\u0026nbsp;1, item 1). About learning motivation and interest, 70% of students in TBL and 92% of students in PBL agreed or strongly agreed that active learning \u0026ldquo;increases my learning motivation and interest\u0026rdquo; (Fig.\u0026nbsp;1, item 5). Both in TBL (50%) and in PBL (92%), students agreed or strongly agreed that they \u0026ldquo;liked the study goals designed in TBL/PBL\u0026rdquo; (Fig.\u0026nbsp;1, item 8) (Figs.\u0026nbsp;1 and 2). When it came to examination, the questionnaire asked the students\u0026rsquo; opinion about the effects of TBL/PBL on their final examination. Most students did not know whether \u0026ldquo;Useful to my final examination\u0026rdquo; (TBL:60%, PBL:38%, Fig.\u0026nbsp;1, item 4). However, 69% agreed or strongly agreed that learning basic knowledge was well suited for PBL, whereas 40% thought TBL was well suited for learning basic knowledge (Fig.\u0026nbsp;1, item 2). Not only TBL (90%) but also PBL (77%) was useful for clinical thinking, such as questions of clinical application in an examination (Fig.\u0026nbsp;1, item 3). Regarding study burden, 40% of the students in TBL and 46% in PBL agreed or strongly agreed that active learning \u0026ldquo;added to my study burden\u0026rdquo; (Fig.\u0026nbsp;1, item 6). In TBL, 50% agreed or strongly agreed that the teachers were more helpful, compared with 31% in PBL (Fig.\u0026nbsp;1, item 7) (Fig.\u0026nbsp;1 and Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudents\u0026rsquo; view regarding PBL and TBL features\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePBL\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTBL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThis approach can develop students' ability, such as\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecritical thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.31%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eteam-working skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eleadership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecommunication skills\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.62%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eprofessional ability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eclinical thinking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost useful aspects of this approach, such as\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edeveloping studying interest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egetting the answers directly from the teachers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eimproving ability of expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ehelping to understand professional knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46.15%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edeveloping ability of self-study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.08%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost different aspect of this approach, such as\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edifferences between cases and contents in the book\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.08%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etime limitation in the class\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003etime limitation in self-study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evarying quality of cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.92%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026ldquo;Analyzing, synthesizing and solving problems\u0026rdquo; is another ability that some students think can be trained by TBL.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e\u0026ldquo;Learning mechanism and developing clinical thinking\u0026rdquo; is another useful aspect in PBL.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \n\n\u003cp\u003eThe students\u0026rsquo; views on the features of PBL and TBL are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The students thought clinical thinking, critical thinking, communication skills and team-working were trained well in these two approaches, with clinical thinking ranking first in PBL and team-working first in TBL. In addition, some students (20%) considered the ability to analyze, synthesize and solve problems to be well trained through TBL. In PBL, 46.15% of students viewed that this approach was helpful for understanding professional knowledge. Some students (7.69%) also listed \u0026ldquo;Learning mechanism and developing clinical thinking\u0026rdquo; as another advantage of PBL. The cases used in class vary in quality. Those with low quality pose difficulty for study (76.92%). When it came to TBL, students reported that the instructor\u0026rsquo;s help in class was the most popular aspect (50%). Time limitation and cases with low quality were the most difficult aspects for them (40%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\n\n\u003cp\u003eThe questionnaire also asked for the students\u0026rsquo; opinion about which approach they preferred to study in this module. Most students (69.23%) in PBL preferred PBL, whereas some students (30%) in TBL chose TBL (Fig.\u0026nbsp;3).\u003c/p\u003e \u003cp\u003eTime students spent in PBL study and TBL study\u003c/p\u003e \u003cp\u003eThe time students spent preparing for TBL/PBL can be seen in Fig.\u0026nbsp;4. Most TBL students (80%) spent 1 to 3 hours preparing for each lesson, while most PBL students (76.92%) spent 4\u0026ndash;6 hours collecting materials and preparing for each case (Fig.\u0026nbsp;4).\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cp\u003eThis study compared the PBL and TBL students\u0026rsquo; views and their academic scores in Chinese basic medical curriculum homeostasis module and observed the following differences.\u003c/p\u003e\n\u003ch2\u003eTBL and PBL are popular among students\u003c/h2\u003e\n\u003cp\u003eAlthough Janneke pointed out that a certain incongruity between Chinese and Western cultures, such as a traditional secondary education, a hybrid curriculum and examination content, complicates the straightforward transfer of the new teaching approaches to such cultural contexts [19], our results show both PBL and TBL were popular among students. These results are similar to a previous study showing PBL and TBL could motivate students to study. Considering the characteristics of these two approaches, we speculate that the results may be due to the following reasons. Chinese students have used the LBL teaching model for more than 10 years since their primary education, and the new teaching approaches are a novelty that has greatly stimulated students\u0026rsquo; interest in learning [5]. Harun et al. pointed out that three components affected students\u0026rsquo; motivation to study: the importance of the task, the student\u0026rsquo;s ability to perform the task and their emotional reactions to the task [20]. Based on these three aspects, students were no longer given lectures during TBL and PBL. On the contrary, they worked together, exchanged their opinions and solved the problems. Therefore, they have more freedom, which would add to their motivation to study [20].\u003c/p\u003e\n\u003ch2\u003eEffects of TBL and PBL on learning outcomes\u003c/h2\u003e\n\u003cp\u003ePrevious studies found that students receive higher academic scores due to these active learning approaches [5, 21]. From our questionnaire, most students did not know whether these two approaches were appropriate for passing the final examination. However, students thought that TBL/PBL was useful for basic knowledge and clinical thinking. We speculate that the results may be due to the extra textbooks and articles in these two approaches. Comparing with LBL class, students in PBL and TBL think that these two approaches requires them to read some up-to-date articles and textbooks which are not included in the final examination but can help them to learn more basic knowledge and train their clinical thinking.\u003c/p\u003e\n\u003cp\u003eContrary to foreign studies [11, 21-23], in our study neither TBL nor PBL students showed any advantages on academic test scores and memorization questions, as compared with LBL students. This could be explained by differences in higher medical education between China and the West [5]. One of the most important differences is the diversity of reference textbooks in western countries. Most Chinese medical colleges prefer to use the same books across the country, whereas medical colleges in western countries do not use uniform textbooks or standard lecture formats [5]. In this study, the TBL and PBL students used the same references as LBL students. Before the final examination, all students would have reviewed the same basic knowledge. Furthermore, some articles pointed out that the evaluation of the effectiveness of these two approaches were still unsophisticated, particularly for basic medical education [5, 24]. In medical education in China, theory courses often occupy the most teaching time, with the largest proportion of learning contents in the final examination, which cannot completely evaluate students\u0026rsquo; learning ability in PBL and TBL [5, 24]. Therefore, a more relevant assessment system should be implemented, such as adding laboratory course examinations [5]. Although academic test scores did not show any differences with LBL, we still think that motivation, increased by PBL and TBL, can be life-long and in the long run would benefit student to future learning.\u003c/p\u003e\n\u003cp\u003eEven though in TBL there were no differences from LBL, students taught by PBL received higher scores in clinical questions. Considering the differences between TBL and PBL, the following reasons may explain the results. Although TBL is an active learning approach and motivates students, it is a teacher-directed instructional approach, which means the teacher, rather than students, decides the learning content. PBL is a student-centered approach in which students generate issues according to what they do not understand [16]. In this aspect, students study and improve on an individual basis in PBL. In addition, PBL presents advantages with respect to improving student abilities in clinical thinking [6-8]. Compared with lecture notes (such as PowerPoint presentations) in the LBL and the tests designed by professors in the TBL, PBL students use clinical cases, adapted from real patients, which is closer to the clinical situation and could better train clinical thinking.\u003c/p\u003e\n\u003ch2\u003eThe burden of TBL and PBL\u003c/h2\u003e\n\u003cp\u003eFrom the student feedback, there are no significant differences in study burden between PBL and TBL. However, we could see that students usually spent more time preparing for PBL than TBL. The characteristics of these two approaches determine these differences. Students in TBL just need to understand the assignments and textbooks, whereas in PBL students not only are required to assimilate knowledge in the textbooks, but also research information about medical situations and updated clinical principles online, which increases the student burden [16]. Furthermore, it was proposed that during PBL additional work between cases and exploration of blind methods seemed like busy work to the learners [25]. Some students in PBL, especially \u003ca href=\"https://www.hujiang.com/ciku/lowerclassman/\"\u003elowerclassmen\u003c/a\u003e, spend a large amount of useless time searching information blindly rather than assimilating knowledge or training abilities. Therefore, it is necessary for medical schools to implement \u003ca href=\"http://dict.cn/a%20tailor-made%20course%20of%20study\"\u003ea tailor-made courses of study \u003c/a\u003efor \u003ca href=\"https://www.hujiang.com/ciku/lowerclassman/\"\u003elowerclassmen\u003c/a\u003e to learn how to increase information retrieval effectiveness on basic medical curriculum. On the other hand, apart from developing students\u0026rsquo; learning abilities, the case writers could give some search material clues to students in PBL to relieve some study pressure.\u003c/p\u003e\n\u003ch2\u003eEffect of instructors in TBL and PBL\u003c/h2\u003e\n\u003cp\u003eAlthough instructors guided the discussion in PBL, student feedback suggested professors were more helpful in TBL than in PBL, possibly because PBL is student-centered and TBL is teacher-directed, so the professor plays different roles in these two approaches [16]. In PBL, the professor encourages students to discuss topics critically and engages students to raise and solve problems. On the contrary, in TBL, the professor gives a quiz first, facilitates the discussion, and even answers the questions during the class. However, since each discussion group requires one instructor, PBL has the disadvantage of requiring a greater number of professional instructors [26, 27]. On account of limitations on instructor-conditions, teacher training is essential. Salah emphasized that effective PBL instructors required multiple skills that are positively related to their role in large group lectures, which could have implications for recruiting PBL instructors in medical programs [28]. Furthermore, peer teaching seems to be a good way to solve the shortage of teachers. Peer teaching is beneficial for not only student teachers, but also learners [29, 30].\u003c/p\u003e\n"},{"header":"Conclusion","content":" \u003cp\u003eEven though there are differences between Chinese and Western cultures, TBL and PBL are two popular teaching approaches among Chinese medical students in the basic medical curriculum. Furthermore, the PBL teaching approach is more effective in training clinical thinking, while the TBL teaching approach does not add to the study burden of students, and the teachers in this approach play a greater role. However, for Chinese medical students to better adapt to these two teaching approaches, during study, both TBL and PBL need to be adjusted according to the actual situation. The relevant assessment system and teacher training system should be perfected. For ease students\u0026rsquo; burden, it is necessary for medical schools to introduce the topic, such as literature searching, in the appropriate class.\u003c/p\u003e \u003cp\u003eStudy limitations\u003c/p\u003e \u003cp\u003eBecause our study was only developed at SUMC, and the selection criteria of ALC students was strict, the sample size was limited. In addition, this study was only conducted in one basic medical curriculum and did not collect feedback from PBL and TBL teachers. Therefore, further research will enlarge the sample size and collect more data not only from students, but also from teachers, to compare PBL and TBL on the basic medical curriculum.\u003c/p\u003e "},{"header":"Abbreviations","content":" \u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eProblem-based learning\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 \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eLBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eLecture-based learning\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eALC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eActive Learning Class\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSUMC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eShantou University Medical College\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Research Ethics Committee of Shantou University Medical College. All participants were informed that their participation was voluntary. The study objective was explained to all participants, which was proved by the ethics committee. All online surveys were anonymized and untraceable. No individual subject identifiers were collected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent for publication was obtained from all authors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was financially supported by Ministry of Education Humanities and Social Science Project (No. 17YJA740063) and Guangdong Province Education Promotion Project (No. [2018]68) in People\u0026rsquo;s Republic of China. The funding body did not play any roles in the design of the study, collection, analysis, and interpretation of the data, and writing the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLX contributed to study design, data collection, data analysis and drafting of the manuscript. CX contributed to data analysis. XX, CM, M, HB, FF, CX contributed to study design and critical review of the manuscript. All authors read and reviewed the final version of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLX and XX are all the undergraduate medical students of Shantou University Medical College. HB, CM, M, FF, CX are professors of Shantou University Medical College.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge and thank the students who participated in this research. We thank Stanley Lin for proofreading the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e \u003cspan\u003eLetassy NA, et al. Using team-based learning in an endocrine module taught across two campuses. Am J Pharm Educ. 2008;72(5):103.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eBurgess A, et al. Implementation of modified team-based learning within a problem based learning medical curriculum: a focus group study. BMC Med Educ. 2018;18(1):74.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eJones RW. Problem-based learning: description, advantages, disadvantages, scenarios and facilitation. Anaesth Intensive Care. 2006;34(4):485\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eMcParland M, Noble LM, Livingston G. The effectiveness of problem-based learning compared to traditional teaching in undergraduate psychiatry. Med Educ. 2004;38(8):859\u0026ndash;67.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eZhang Y, et al. The effectiveness of the problem-based learning teaching model for use in introductory Chinese undergraduate medical courses: a systematic review and meta-analysis. PLoS One. 2015;10(3):e0120884.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eAbraham RR, et al. Learning approaches of undergraduate medical students to physiology in a non-PBL- and partially PBL-oriented curriculum. Adv Physiol Educ. 2008;32(1):35\u0026ndash;7.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eChou FH, Chin CC. Experience of problem-based learning in nursing education at Kaohsiung Medical University. Kaohsiung J Med Sci. 2009;25(5):258\u0026ndash;63.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eEnarson C, Cariaga-Lo L. Influence of curriculum type on student performance in the United States Medical Licensing Examination Step 1 and Step 2 exams: problem-based learning vs. lecture-based curriculum. Med Educ. 2001;35(11):1050\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDolmans D, Schmidt H. The advantages of problem-based curricula. Postgrad Med J. 1996;72(851):535\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDavis MH, Medical Education AMEE. Guide No. 15: Problem-based learning: a practical guide. Med Teach. 1999;21(2):130\u0026ndash;40.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eAlbanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993;68(1):52\u0026ndash;81.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eIputo JE, Kwizera E. Problem-based learning improves the academic performance of medical students in South Africa. Med Educ. 2005;39(4):388\u0026ndash;93.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSchmidt HG, Cohen-Schotanus J, Arends LR. Impact of problem-based, active learning on graduation rates for 10 generations of Dutch medical students. Med Educ. 2009;43(3):211\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eKoh GC, et al. The effects of problem-based learning during medical school on physician competency: a systematic review. CMAJ. 2008;178(1):34\u0026ndash;41.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eEnglander R, et al. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88(8):1088\u0026ndash;94.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDolmans D, et al. Should we choose between problem-based learning and team-based learning? No, combine the best of both worlds! Med Teach. 2015;37(4):354\u0026ndash;9.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eKaufman DM. Applying educational theory in practice. BMJ. 2003;326(7382):213\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eThompson BM, et al. Evaluating the quality of learning-team processes in medical education: development and validation of a new measure. Acad Med. 2009;84(10 Suppl):S124-7.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eFrambach J, et al. Rethinking the globalisation of problem-based learning: how culture challenges self-directed learning. Med Educ. 2012;46:738\u0026ndash;47.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eNor Farida Harun A, K.M.Y.B. and Hassan AHS, Motivation in Problem-based Learning Implementation. Procedia - Social and Behavioral Sciences 56 (2012) 233\u0026ndash;242, 2012.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eHashmi NR. Team Based Learning (TBL) in undergraduate medical education. J Coll Physicians Surg Pak. 2014;24(8):553\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eDochy F, S.M.B.V., Effects of problem-based learning: a meta-analysis. Learning and Instruction. 2003; 13:533\u0026ndash;68., 2003.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eNorman GR, Schmidt HG. Effectiveness of problem-based learning curricula: theory, practice and paper darts. Med Educ. 2000;34(9):721\u0026ndash;8.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eChen M, et al. Meta-analysis on the effectiveness of team-based learning on medical education in China. BMC Med Educ. 2018;18(1):77.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSrinivasan M, et al. Comparing Problem-Based Learning with Case-Based Learning: Effects of a Major Curricular Shift at Two Institutions. Acad Med. 2007;82(1):74\u0026ndash;82.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eSwanwick T. Informal learning in postgraduate medical education: from cognitivism to 'culturism'. Med Educ. 2005;39(8):859\u0026ndash;65.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eHealth workforce. 2025\u0026ndash;doctors, nurses and midwives. Adelaide: Health Workforce Australia; 2012.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eKassab SE, et al. lecturing skills as predictors of tutoring skills in a problem-based medical curriculum. Advances in Medical Education Practice. 2016;7:1\u0026ndash;6.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eGraham K, Burke JM, Field M. Undergraduate rheumatology: can peer-assisted learning by medical students deliver equivalent training to that provided by specialist staff? Rheumatology (Oxford), 2008. 47(5): p.\u0026nbsp;652\u0026ndash;5.\u003c/span\u003e \u003c/li\u003e \u003cli\u003e \u003cspan\u003eCate OT, Durning S. Peer teaching in medical education: twelve reasons to move from theory to practice. Medical Teaacher. 2007;29:591\u0026ndash;9.\u003c/span\u003e \u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Problem-based learning, Team-based learning, Basic-medical curriculum","lastPublishedDoi":"10.21203/rs.3.rs-23853/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-23853/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSince being proposed half a century ago, problem-based learning (PBL) and team-based learning (TBL) have been two popular teaching approaches used in Chinese basic medical education. To compensate for the shortcomings of lecture-based learning (LBL), both PBL and TBL can greatly benefit students. This study compares the differences of PBL and TBL on active learning and final academic scores in Chinese basic medical curriculum at Shantou University Medical College (SUMC).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTen Year 4 and thirteen Year 3 medical students, enrolled in 2015 and 2016\u0026nbsp;at SUMC, were selected for TBL and PBL, respectively. In the homeostasis module, a basic-medical curriculum used in China, TBL was used for Year 4 students at their 3rd year, and PBL was used for Year 3 students. Student feedback was collected through a questionnaire. Academic achievement was based on their final examination scores. Each grade used the same final examination paper, which included both memorization and clinical application questions, as students in the traditional LBL class. Quantitative data were analyzed by t- and nonparametric tests.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAll students completed the questionnaire. Most students (PBL:62%, TBL:90%) thought the teaching approach they used was good for training clinical thinking, but PBL required more time and imposed a greater study burden. However, PBL students received higher scores than LBL students for clinical application essays (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), whereas there were no differences in memorization problem scores. Final academic scores showed no significant differences between TBL and LBL students (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDespite the differences in the culture of learning between China and the West, TBL and PBL are two popular teaching approaches among Chinese medical students. In Chinese basic medical education, PBL is more effective in training clinical thinking, while in TBL, students spend less time with problems and are helped by the professors. The relevant assessment system and teacher training system should be perfected.\u003c/p\u003e","manuscriptTitle":"Comparison of problem-based and team-based learning on Chinese basic medical education for clinical medicine: a pilot study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-05-01 17:00:48","doi":"10.21203/rs.3.rs-23853/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36ab8f52-dbd1-4e33-99bb-4b4c2811377d","owner":[],"postedDate":"May 1st, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":92623,"name":"Internal Medicine"},{"id":92624,"name":"Educational Philosophy and Theory"}],"tags":[],"updatedAt":"2020-05-06T20:30:19+00:00","versionOfRecord":[],"versionCreatedAt":"2020-05-01 17:00:48","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-23853","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-23853","identity":"rs-23853","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}