Evaluationof Integrated Modular Teaching in Chinese Ophthalmology Trainee Courses

Evaluationof Integrated Modular Teaching in Chinese Ophthalmology Trainee Courses | 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 Evaluationof Integrated Modular Teaching in Chinese Ophthalmology Trainee Courses Wei Xin, Yuxian Zou, Yong Ao, Yu Cai, Zheqian Huang, Miaoling Li, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.2.12632/v3 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 May, 2020 Read the published version in BMC Medical Education → Version 3 posted 4 You are reading this latest preprint version Show more versions Abstract Background: Before attending ophthalmology trainee courses in Zhongshan Ophthalmic Centre, the medical students from Sun Yat-sen University had finished two years of premedical education after the six-year medical courses including basic medical courses, clinical medical courses, clerkship, and research training in medical college. Integrated modular teaching using different problem-based teaching methods in ophthalmology was designed by the teaching steering committee of Zhongshan Ophthalmic Centre. This study aimed to evaluate the effectiveness and satisfaction scales of the integrated modular teaching among the trainee students. Methods: A total of 100 medical students attending ophthalmology trainee courses in Zhongshan Ophthalmic Centre were enrolled and randomly allocated into 4 groups according to the teaching arrangement. The trainee courses consisted of several sessions delivered in multiple methods, such as "flipped classroom" session and team-based learning session. The pre- and post-class tests were delivered to evaluate the effectiveness of the integrated modular teaching. The satisfaction survey questionnaire was collected from all participants to investigate the degree of satisfaction. Results: Compared with the first-day-test score, the total last-day-test score was significantly improved by a paired t- test ( t =3.288, P =0.001). Nineteen students obtained a significant improvement in ranking increased by more than 10 in the last-day-test, whereas they failed to obtain a higher average score for daily performance than other students ( t =0.469, P =0.654). According to the participant satisfaction questionnaires, these innovative teaching methods were considered as effective and satisfactory. Conclusions: Integrated modular teaching in ophthalmology trainee courses is effective and widely recognized by the medical college students. Educational Philosophy and Theory Ophthalmology Ophthalmology Teaching Effectiveness Problem-based Trainee course Figures Figure 1 Figure 2 Background Ophthalmology is an independent and essential subject in medical teaching in which clinical-skill training and patient interaction play indispensable roles [1]. However, many medical students lack of sufficient practice in ophthalmology due to insufficient teaching time [2,3] . In addition, the teaching style that most medical colleges employ in teaching ophthalmology may lack efficiency and student interest. With the advancement in science and technology and multimedia innovations over the last several decades, new teaching methodologies have been introduced into medical teaching to improve the learning efficiency, shorten classroom learning time and develop students’ ability for autonomous learning. Because ophthalmology is a discipline that emphasizes practice, multimedia teaching method should be adopted to demonstrate a variety of ocular pictures and videos and to emphasize the items of information repeatedly. "Flipped classroom" (an inverted model of teaching that uses videos, podcasts or slides to deliver lecture materials outside the classroom, therefore, the classroom time is mainly spent on discussion or problem-solving [4]), team-based learning (TBL) [5], simulation scenarios [6], figure demonstrations [7] and video demonstrations [8] have been shown as effective teaching methodologies to promote the transformation of teaching from a teacher-centred approach to one that focuses on medical students. The use of TBL has been applied in ophthalmology teaching and has proven to be an effective means of active learning [9]. However, most teaching assessments have been implemented based on one or two teaching methodologies [10,11,12,13]. Most subjects, including ophthalmology, seldom use a single model for teaching. Instead, a multi-mode teaching model is frequently employed in the actual teaching process. Because every student has a preferred learning mode, it is necessary to integrate a variety of teaching modes to satisfy the students’ needs and improve their learning efficiency. Recently, integrated modular teaching using different teaching methodologies has yielded improved results in dermatology [7]. In the present study, 100 medical students from Sun Yat-sen University took part in an ophthalmology curriculum, which was designed to incorporate multiple innovative teaching methodologies. This study was designed to assess the effectiveness and the students’ degree of satisfaction among different innovative teaching methods, aiming to evaluate the validity and feasibility of integrated modular teaching in ophthalmology by using pre-, post-class tests and daily performance. Methods Participants In this prospective study, 100 medical students who were entering their ninth semester in August 2015 and taking classes in Sun Yat-sen University were enrolled. All students were randomly allocated into 4 groups in order to guarantee the teaching quality. The students participated in a 1-week of integrated modular ophthalmology learning course in Zhongshan Ophthalmic Centre. All the procedures in this study were videotaped, with the approval of the institutional review board of Zhongshan Ophthalmic Centre of Sun Yat-sen University (IRB-ZOC-SYSU) (Ethic ID: 2016MEKY062). Written informed consents have been obtained from all students. Integrated modular teaching Each module was initiated by a clinical teacher from Zhongshan Ophthalmic Centre with a suitable introduction, followed by a discussion of individual topics. Pre- and post-class tests were conducted at the beginning of the first module and the end of the last module, respectively, to assess the effectiveness of the integrated modular teaching system. Test papers were designed based on the teachers’ discussions and approved by the examination administration of Sun Yat-sen University. The topics of these modules included the anatomy of the eye, ophthalmologic examination, the lids and lacrimal apparatus, conjunctivitis and uveitis, keratitis, glaucoma, cataract and refractive error, the retina and ocular disorders associated with systemic disease, ocular trauma and blindness (Table 1). A comprehensive evaluation was conducted among all the enrolled students based on the comparison between the first-day and last-day test scores before and after 1-week of integrated modular teaching with innovative teaching methods. The details of the questionnaire utilized in the comprehensive evaluation are illustrated in Supplementary materials. The questionnaire consisted of two parts. The first part was a case with chief complains of single eye redness and blurred vision. Three questions about important signs, diagnosis and recommended examinations of this case were listed to be answered. The second part contained a list of important ocular symptoms and signs, such as photophobia, tearing, itch sensation, foreign-body sensation and swelling pain, etc . Five cases were presented in the 2 nd part and the students were asked to select one or more related symptoms or signs for each case. "Flipped classroom" session The "flipped classroom" protocol was used for the ocular trauma teaching among the fifth-year medical college students [14]. Before the "flipped classroom", relevant knowledge and questions based on one case of single ocular trauma were delivered by email. The students were asked to overview the knowledge of ocular trauma in groups using textbooks, published articles, e-publications or any other reference besides the email. At 3 days before the "flipped classroom" session, the students were directed to review the subject of ocular trauma. One test consisting of three cases was completed by students in 20 minutes at 1 day before the "flipped classroom" session. These three cases focused on penetrating injuries, contusions of the eyeball and chemical burns. Two or three questions were appended to each case scenario. Before the end of the course, a post-class test was administered immediately to obtain feedback. Simultaneously, a questionnaire was finished by each student to investigate the satisfaction scale. Team-based learning module The TBL module [15] was designed according to the guidance [16], which included Individual Readiness Assurance Test (IRAT), preparatory assignments, Group Readiness Assurance Test (GRAT), Group Application Problem (GAP) and Final Examination Scores (FESs). In each group, students were given with a random topic in the morning of the first-day trainee course. The topics were closely linked to the content in this curriculum. The students had to prepare any form of presentation within 5 days according to the assigned topic. Other relevant medical knowledge in addition to ophthalmology was permitted to be discussed in the presentation or display. After students in each group presented their team-work presentations in class, the teachers graded the students’ presentations into 5 criteria. Statistical analysis The pre- and post-class-test scores, and the first- and last-day-test scores were statistically compared by using paired t -test at the significance level of 0.05. One-way analysis of variance (ANOVA) was used to compare the average scores among different groups or teaching methods. All data analyses were performed using SPSS 20.0 statistical software (SPSS Inc., Chicago, IL, USA). Results Baseline data A total of 100 students, 50 male and 50 female, aged from 22 to 28 years old, were recruited. The following information was collected from the student record department of the university: 1) The admission scores for the medical college were collected and no significant difference was observed in the admission scores among four groups ( F =0.520, P =0.669), 2) The final grade for all curricula, which are provided as a standard numerical grade (SNG) on a scale from 0 to 100, including the following subjects: Obstetrics and Gynecology, Pediatrics, Psychiatry, Neurology, Emergency Medicine, Disaster Medicine, Otolaryngology Head and Neck Surgery, Anesthetics, Dermatovenerology, Internal Medicine, Surgery, and Ophthalmology, and there was no significant difference in the final grade for all curricula among four groups, 3) The final grade of ophthalmology theory did not significantly differ among four groups. Completion rate All the 100 clinical medical students who took part in the ophthalmology trainee courses completed pre- and post-class tests in the integrated modular teaching provided by Zhongshan Ophthalmic Centre. All data were collected and analysed. Eight clinical teachers jointly completed the innovative teaching work. No complaints from the students were reported throughout the trainee process. E ffectiveness of TBL and "flipped classroom" session s The average scores of pre- and post-class tests in both TBL and "flipped classroom" sessions were calculated and analyzed. The pre- and post-class test scores in each group were statistically compared by using a paired t - test. The total students' scores in each group were improved in the post-class test during both TBL and "flipped classroom" sessions (TBL: t =12.208, P =0.000; "flipped classroom": t =37.822; P =0.000) (Figure 1). The students’ questionnaires were collected and their acceptance of these two new teaching methods was evaluated by calculating the number of students who responded with “agree” (Table 2). Among them, 70% of the students believed that these two teaching methods were beneficial for learning. The details and survey questions of student perceptions regarding various teaching methods are presented in Table 2. Comprehensive evaluation of the integrated modular teaching A comprehensive evaluation was conducted among all enrolled students by the first-day-test and last-day-test, which were organized before and after the integrated modular teaching with innovative teaching methods for 1 week. The average scores of each group, including the first-day-test and last-day-test, are presented in Figure 2. The first-day-test scores did not significantly differ among four groups by ANOVA test. The paired t - test was used to compare the average score of first-day-test before the trainee courses and the total last-day-test score after the courses. The total last-day-test score was significantly improved ( t =3.288, P =0.001). By comparing the first-day-test and last-day-test scores, 19 students who had outstanding performance with ranking increased by more than 10 in the post-class test were screened. There students were then assigned into the improvement group in Figure 2, and the daily performance of these outstanding students was assessed to discuss whether they paid more attention in the classroom. However, they did not have higher average scores in daily performance than other students ( t =0.469, P =0.654). Most students were satisfied with the innovative teaching methods based on their answers to the questionnaire. A small number of students did not agree with the effectiveness of these new teaching methods, even if their test results were improved. Discussion With the introduction and development of multimedia, computers and the internet in this information era, modern technologies can increasingly be used to replace the previous teaching methods and to usher in an era of rich teaching resources. The applications of modern technology and abundant public learning resources have promoted a reform from previous teacher-centred to student-centred teaching modes. Student-centred teaching can cultivate higher-order thinking, problem solving and critical analysis, and provide feedback on the learning process [17]. Learning is a complex process, and previous studies have confirmed that increasing active learning can produce a better learning result [18,19]. Recently, a variety of student-centred teaching methods have been conducted in medical teaching [10,20]. The trainee courses of ophthalmology are established to improve students' knowledge in clinical practice, to guide them to integrate knowledge in theory with practice, and eventually to attract more outstanding students to the ophthalmology profession. All the teaching modules we are conducting are based on problem-solving. In this study, the effectiveness of each major innovative teaching method was evaluated by pre- and post-class tests for 100 medical students. The post-class scores of all students were improved. A majority of students were satisfied with the innovative teaching methods based on their answers to the questionnaire. Because each student has preferred learning habits and thinking modes, it is understandable that a small number of students do not agree with the effectiveness of these new teaching methods, even if their test results are improved. Overall, integrated teaching modes are appropriate for the learning habits of most students. A comprehensive evaluation of integrated teaching modes was conducted by comparing the pre- and post-class test scores. Most students presented with significant improvement in the post-class test scores, suggesting that this multi-mode teaching method is highly effective in ophthalmology trainee courses. In previous teaching styles, the teacher-centred teaching method forces students to passively accept knowledge. The grades of students depend on how they listen in the classroom and review the materials after class. Diligent students can often obtain better grades. Therefore, different learning attitudes among students may make an enormous difference in the degree of knowledge they master. However, these innovative teaching methods are implemented based on student-centred teaching, which stimulates autonomous and active learning of the students. These curricula were designed to comprise different modules using a variety of teaching methods, which can enhance learning interests, reduce boredom and increase the acceptance by students. The multi-mode teaching methods in this study included a "flipped classroom" session, consisted of simulation scenario teaching, case-based learning, and other methods that improved the autonomous learning capability of the students, which plays a pivotal role in the life-long career growth of medical students [21]. Therefore, the education of medical students is not only involved with teaching professional knowledge but also how to take the initiative to study and how to use the educational platforms provided by modern science and technology. In addition, the teamwork capability is of significance for medical students because hospitals are workplaces based on teamwork [22]. The TBL method can teach students how to learn from each other and jointly progress in a team. Compared with other medical subjects, ophthalmology is more closely associated with advanced science and technologies, such as the application of lasers, new materials, and optical instruments, which require ophthalmologists to maintain effective learning and to develop more autonomous learning than other specialists. Therefore, this teaching method might provide particular assistance for medical students who are determined to become ophthalmologists. In our study, the students’ daily performance was analysed. All students had worse daily performances in TBL session than the "flipped classroom" and case-based learning sessions, which was consistent with the questionnaire results. TBL had a lower degree of recognition. A total of 19 students obtained an increase in academic performance by more than 10 points in the post-class test, whereas their daily performance in class or attendance were not better compared with other students, probably prompting that all students have excellent class performance when autonomous learning awareness is triggered. This situation differs from previous learning modes because greater efforts have been made throughout the whole learning process, and more significant improvement has been obtained. Nevertheless, whether the learning effect will decrease over time remains elusive. Hence, these students should be followed up to examine their learning ability and the durability of this method in subsequent investigations. Conclusion In the present study, the integrated modular teaching is an effective teaching method and appreciated by medical college students in ophthalmology trainee courses. It deserves to be introduced to the trainee or teaching process in other medical specialized subjects. Abbreviations TBL, team-based learning; CBL, case-based learning; ANOVA, One-way analysis of variance Declaration Ethics approval and consent to participate All the procedures in this study were approved by the Institutional Review Board of Zhongshan Ophthalmic Center of Sun Yat-sen University (Ethic ID: 2016MEKY062). All subjects gave their written informed consent. Consent for publication Not Applicable Availability of data and materials The datasets used and/or analysed 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 supported by the National Key R&D Program of China (2018YFC0116500), National Natural Science Foundation of China (No. 81770967, 81822010), the Science and Technology Planning Project of Guangdong Province (No.2017B030314025, 2018B010109008, 2019B030316012, 2019A070701006), And Guangdong Science and Technology Innovation Leading Talents (No. 2017TX04R031) . The sponsors of the study played no role in the study protocol design, data collection, data analysis, data interpretation, manuscript preparation, or the decision to submit the manuscript for publication. Authors’ contributions WX performed the collection of the data, and was a major contributor in writing the manuscript. YZ and YA were in charge of the teaching inspectorate and collected the data. YC, ZH and ML analyzed and interpreted the data. CX, YJ and YY collected the data. YFY and HL designed the study protocol and collected the data. All authors read and approved the final manuscript. Acknowledgements Not Applicable References Walsh, K. E-learning in ophthalmology: where next? Indian Journal of Ophthalmology . 2014; 62(12): 1178. Shah, M., et al. The state of ophthalmology medical student education in the United States and Canada, 2012 through 2013. Ophthalmology . 2014; 121(6): 1160-1163. Tsinopoulos, I.T., et al. Contribution of integrated teaching in the improvement of an undergraduate ophthalmology curriculum. Advances in Medical Education and Practice . 2014; 5: 433-437. Strayer, J.F. How learning in an inverted classroom influences cooperation, innovation and task orientation. Learning Environments Research . 2012; 15: 171-193. Burgess, A.W., et al. Applying established guidelines to team-based learning programs in medical schools: a systematic review. Academic Medicine . 2014; 89(4): 678-688. Ahn, H. & Kim, H.Y. Implementation and outcome evaluation of high-fidelity simulation scenarios to integrate cognitive and psychomotor skills for Korean nursing students. Nurse Education Today. 2015; 35(5): 706-711. Karthikeyan, K. & Kumar, A. Integrated modular teaching in dermatology for undergraduate students: A novel approach. Indian Dermatology Online Journal . 2014; 5(3): 266-270. Kurien, G., et al. Can a multisensory teaching approach impart the necessary knowledge, skills, and confidence in final year medical students to manage epistaxis? Journal of Otolaryngology - Head & Neck Surgery . 2013; 42: 51. Altintas, L., et al. Modified use of team-based learning in an ophthalmology course for fifth-year medical students. Advances in Physiology Education . 2014; 38(1): 46-48. Shetty, S.R., et al. Case-based, team-based learning: a novel method for teaching orofacial syndromology to dental undergraduate students. Education for health (Abingdon, England) . 2015; 28(1): 112-113. Wong, T.H., et al. Pharmacy students' performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. American Journal of Pharmaceutical Education .2014; 78(10): 185. Aljarallah, B. & Hassan, M.S. Problem based learning (PBL) vs. Case based curriculum in clinical clerkship, Internal Medicine innovated Curriculum, Student prospective. International Journal of Health Sciences (Qassim) . 2015; 9(2): 147-152. McMullen, I., et al. Team-based learning for psychiatry residents: a mixed methods study. BMC Medical Education . 2013; 13: 124. Yang Y, Xu C-C, Jia Y, et al. Flipped classroom approach to ophthalmology clerkship courses for Chinese students of eight-year program. Annals of Eye Science. 2017;2(7). Huang, Z., et al. Modified team-based learning in an ophthalmology clerkship in China. PLoS One . 2016; 11(4): e0154250. Parmelee D.X. & Michaelsen L.K. Twelve tips for doing effective Team-Based Learning (TBL). Med Teach. 2010; 32(2): 118–122. Gleason, B.L., et al. An active-learning strategies primer for achieving ability-based educational outcomes. American Journal of Pharmaceutical Education . 2011; 75(9): 186. Harakuni, S.U., et al. Effectiveness of team-based learning in microbiology: a non-randomized control study. Education for health (Abingdon, England) . 2015; 28(1): 41-44. Jensen, J.L., et al. Improvements from a flipped classroom may simply be the fruits of active learning. CBE-Life Science Education . 2015; 14(1): ar5. Steedman, M., et al. Multimedia learning tools for teaching undergraduate ophthalmology: results of a randomized clinical study. Canadian Journal of Ophthalmology . 2012; 47(1): 66-71. Dornan, T. Workplace learning. Perspectives on Medical Education . 2012; 1(1): 15-23. Watts, B., et al. Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems. Population Health Management . 2016; 19(4): 232-239. Tables Table1 Modular teaching on topics of ophthalmology and teaching methodologies. Teaching methodology Module Description Lecture Anatomy of the eye Systematic introduction to sensitize and familiarize the student with certain concepts and clinic features through PPT Ophthalmologic examination Lids and lacrimal apparatus Cataract and refractive error Retina and ocular disorders associated with systemic disease Video demonstration Anatomy of the eye Video demonstration of all the steps of a procedure Retina and ocular disorders associated with systemic disease Practice Anatomy of the eye Basic ophthalmic examination practice and dissecting a pig eyeball Ophthalmologic examination,Cataract and refractive error Photo demonstration Lids and lacrimal apparatus A series of images of various manifestations of the disease were demonstrated by projection. The students had to describe what they saw and attempt to explain the correlation with the clinical condition Retina and ocular disorders associated with systemic disease Case-based learning (CBL) Conjunctivitis and uveitis, Keratitis Typical cases from outpatient clinic or hospital ward were demonstrated. The students had to inquire about medical history, collect clinical examination information and attempt the diagnosis. A summary of key learning points was given by the clinical teacher Simulation scenario teaching Glaucoma Clinic teachers and students play patients with ocular disease and doctors in a scenario, o, respectively. Students acted as doctors and asked questions. A summary of key learning points was given by the clinical teacher. Flipped classroom Ocular trauma Some problems were raised from the learning material by the teacher. The students had to self-study all content, answer all questions and provide new questions for the discussion in class. Team-based learning (TBL) Blindness Students of each group had to complete a presentation associated with the given topic. Table2 Survey of Student Perceptions Regarding Two Teaching Methods Number of Strongly Agree/Agree Responses (%) Survey Question Flipped classroom Team-based learning It helped me to reach a higher level of knowledge 93.30 89.41 It was an effective, motivating learning process 89.90 83.53 It was well organized 100.00 94.12 It challenged me to give my best 95.00 81.18 It had a positive impact on my learning attitudes 93.20 78.82 I was satisfied with this teaching method 89.80 75.29 It should be offered more frequently 81.40 75.29 Cite Share Download PDF Status: Published Journal Publication published 18 May, 2020 Read the published version in BMC Medical Education → Version 3 posted Editorial decision: Accept 11 May, 2020 Editor assigned by journal 30 Apr, 2020 Editor invited by journal 29 Apr, 2020 Submission checks completed at journal 05 Aug, 2019 You are reading this latest preprint version Show more versions 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-3376","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":563609,"identity":"81d229dd-429b-4928-8406-1f06a703fa8a","order_by":1,"name":"Wei Xin","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Wei","middleName":"","lastName":"Xin","suffix":""},{"id":563610,"identity":"efb12ad6-64fa-4de3-86c3-e1b5c3a553d6","order_by":2,"name":"Yuxian Zou","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuxian","middleName":"","lastName":"Zou","suffix":""},{"id":563611,"identity":"01656d58-5861-40bf-a86a-b3820c06dbba","order_by":3,"name":"Yong Ao","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Ao","suffix":""},{"id":563612,"identity":"f53ad4ed-3366-45d6-85e7-4577b43fbbd3","order_by":4,"name":"Yu Cai","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Cai","suffix":""},{"id":563613,"identity":"10aea5f2-90ab-4b40-a1a4-96f00ebb0a43","order_by":5,"name":"Zheqian Huang","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zheqian","middleName":"","lastName":"Huang","suffix":""},{"id":563614,"identity":"73434460-9e68-4589-b884-378670a17929","order_by":6,"name":"Miaoling Li","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Miaoling","middleName":"","lastName":"Li","suffix":""},{"id":563615,"identity":"a8d60965-d8e3-4a1f-b577-5321a10caa23","order_by":7,"name":"Chaochao Xu","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chaochao","middleName":"","lastName":"Xu","suffix":""},{"id":563616,"identity":"55b2c827-7c18-4b17-a184-a2cb4484c62d","order_by":8,"name":"Yu Jia","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Jia","suffix":""},{"id":563617,"identity":"d29d2963-5dcd-44ca-8330-64a47e71650d","order_by":9,"name":"Ying Yang","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ying","middleName":"","lastName":"Yang","suffix":""},{"id":563618,"identity":"f58fe85d-1a65-48cc-8b1e-7284c1b9a3c8","order_by":10,"name":"Yangfan Yang","email":"","orcid":"","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yangfan","middleName":"","lastName":"Yang","suffix":""},{"id":563619,"identity":"e351630d-104e-4514-a83f-49f75b9ad9d2","order_by":11,"name":"Haotian Lin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYBACAzBZIMHALwFmScgQo4WxgcFAgkFyBojBIMFDrBYg4wZYCwNhLebsh48/YDCwyDO+3Xz80Y0aCx4G9sNHN+DTYtmTlghyWLHZnWOJzTnHgA7jSUu7gddhB3IMQVoSt93IMWzOYQNqkeAxw6/l/BuIls0zQFr+EaPlBtSWDRJALbltRGl5ljgjAahlxo20xNm5fRI8bAT9cj75wIcPFXWJ/TOSD3zO+VYnx89++BheLWCQgMxhI6h8FIyCUTAKRgFBAADwuUaUhRmpgQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-4672-9721","institution":"Sun Yat-Sen University Zhongshan Ophthalmic Center","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Haotian","middleName":"","lastName":"Lin","suffix":""}],"badges":[],"createdAt":"2019-08-05 12:59:54","currentVersionCode":3,"declarations":"","doi":"10.21203/rs.2.12632/v3","doiUrl":"https://doi.org/10.21203/rs.2.12632/v3","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12909-020-02073-w","type":"published","date":"2020-05-19T00:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":1105086,"identity":"a0ab7d1a-e645-4677-8c21-1c33deca82fb","added_by":"auto","created_at":"2020-05-15 14:40:32","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25858,"visible":true,"origin":"","legend":"Average scores of the pre-class test and post-class test for team based learning (A) and flipped classroom (B) among the four groups and in total.","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3376/v3/Fig1.jpg"},{"id":1105087,"identity":"cb4529a1-3a4e-4cb6-8f46-61064f6983bd","added_by":"auto","created_at":"2020-05-15 14:40:32","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55008,"visible":true,"origin":"","legend":"Average scores of each group in comprehensive evaluation. We picked out 19 students who had an increase in academic performance by more than 10 grades in the post-test, which were called improvement group.","description":"","filename":"Fig2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3376/v3/Fig2.jpg"},{"id":13503797,"identity":"89313394-7ee6-4eb2-b045-b628c536b193","added_by":"auto","created_at":"2021-09-16 23:20:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":363294,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3376/v3/4633d19b-5907-4096-80d2-72df7f6462cb.pdf"}],"financialInterests":"","formattedTitle":"Evaluationof Integrated Modular Teaching in Chinese Ophthalmology Trainee Courses","fulltext":[{"header":"Background","content":"\u003cp\u003eOphthalmology is an independent and essential subject in medical teaching in which clinical-skill training and patient interaction play indispensable roles [1]. However, many medical students lack of sufficient practice in ophthalmology due to insufficient teaching time [2,3] . In addition, the teaching style that most medical colleges employ in teaching ophthalmology may lack efficiency and student interest. With the advancement in science and technology and multimedia innovations over the last several decades, new teaching methodologies have been introduced into medical teaching to improve the learning efficiency, shorten classroom learning time and develop students\u0026rsquo; ability for autonomous learning. Because ophthalmology is a discipline that emphasizes practice, multimedia teaching method should be adopted to demonstrate a variety of ocular pictures and videos and to emphasize the items of information repeatedly.\u003c/p\u003e\n\u003cp\u003e\"Flipped classroom\" (an inverted model of teaching that uses videos, podcasts or slides to deliver lecture materials outside the classroom, therefore, the classroom time is mainly spent on discussion or problem-solving [4]), team-based learning (TBL) [5], simulation scenarios [6], figure demonstrations [7] and video demonstrations [8] have been shown as effective teaching methodologies to promote the transformation of teaching from a teacher-centred approach to one that focuses on medical students. The use of TBL has been applied in ophthalmology teaching and has proven to be an effective means of active learning [9]. However, most teaching assessments have been implemented based on one or two teaching methodologies [10,11,12,13]. Most subjects, including ophthalmology, seldom use a single model for teaching. Instead, a multi-mode teaching model is frequently employed in the actual teaching process. Because every student has a preferred learning mode, it is necessary to integrate a variety of teaching modes to satisfy the students\u0026rsquo; needs and improve their learning efficiency. Recently, integrated modular teaching using different teaching methodologies has yielded improved results in dermatology [7].\u003c/p\u003e\n\u003cp\u003eIn the present study, 100 medical students from Sun Yat-sen University took part in an ophthalmology curriculum, which was designed to incorporate multiple innovative teaching methodologies. This study was designed to assess the effectiveness and the students\u0026rsquo; degree of satisfaction among different innovative teaching methods, aiming to evaluate the validity and feasibility of integrated modular teaching in ophthalmology by using pre-, post-class tests and daily performance.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eParticipants \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this prospective study, 100 medical students who were entering their ninth semester in August 2015 and taking classes in Sun Yat-sen University were enrolled. All students were randomly allocated into 4 groups in order to guarantee\u0026nbsp;the\u0026nbsp;teaching\u0026nbsp;quality. The students participated in a 1-week of integrated modular ophthalmology learning course in Zhongshan Ophthalmic Centre. All the procedures in this study were videotaped, with the approval of the institutional review board of Zhongshan Ophthalmic Centre of Sun Yat-sen University (IRB-ZOC-SYSU) (Ethic ID: 2016MEKY062). Written informed consents have been obtained from all students.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntegrated modular teaching \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach module was initiated by a clinical teacher from Zhongshan Ophthalmic Centre with a suitable introduction, followed by a discussion of individual topics. Pre- and post-class tests were conducted at the beginning of the first module and the end of the last module, respectively, to assess the effectiveness of the integrated modular teaching system. Test papers were designed based on the teachers\u0026rsquo; discussions and approved by the examination administration of Sun Yat-sen University.\u003c/p\u003e\n\u003cp\u003eThe topics of these modules included the anatomy of the eye, ophthalmologic examination, the lids and lacrimal apparatus, conjunctivitis and uveitis, keratitis, glaucoma, cataract and refractive error, the retina and ocular disorders associated with systemic disease, ocular trauma and blindness (Table 1).\u003c/p\u003e\n\u003cp\u003eA comprehensive evaluation was conducted among all the enrolled students based on the comparison between the first-day and last-day test scores before and after 1-week of integrated modular teaching with innovative teaching methods. The details of the questionnaire utilized in the comprehensive evaluation are illustrated in Supplementary materials. The questionnaire consisted of two parts. The first part was a case with chief complains of single eye redness and blurred vision. Three questions about important signs, diagnosis and recommended examinations of this case were listed to be answered. The second part contained a list of important ocular symptoms and signs, such as photophobia, tearing, itch sensation, foreign-body sensation and swelling pain, \u003cem\u003eetc\u003c/em\u003e. Five cases were presented in the 2\u003csup\u003end\u003c/sup\u003e part and the students were asked to select one or more related symptoms or signs for each case.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\"Flipped classroom\" session\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe \"flipped classroom\" protocol was used for the ocular trauma teaching among the fifth-year medical college students [14]. Before the \"flipped classroom\", relevant knowledge and questions based on one case of single ocular trauma were delivered by email. The students were asked to overview the knowledge of ocular trauma in groups using textbooks, published articles, e-publications or any other reference besides the email.\u003c/p\u003e\n\u003cp\u003eAt 3 days before the \"flipped classroom\" session, the students were directed to review the subject of ocular trauma. One test consisting of three cases was completed by students in 20 minutes at 1 day before the \"flipped classroom\" session. These three cases focused on penetrating injuries, contusions of the eyeball and chemical burns. Two or three questions were appended to each case scenario. Before the end of the course, a post-class test was administered immediately to obtain feedback. Simultaneously, a questionnaire was finished by each student to investigate the satisfaction scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTeam-based learning module\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe TBL module [15] was designed according to the guidance [16], which included Individual Readiness Assurance Test (IRAT), preparatory assignments, Group Readiness Assurance Test (GRAT), Group Application Problem (GAP) and Final Examination Scores (FESs). In each group, students were given with a random topic in the morning of the first-day trainee course. The topics were closely linked to the content in this curriculum. The students had to prepare any form of presentation within 5 days according to the assigned topic. Other relevant medical knowledge in addition to ophthalmology was permitted to be discussed in the presentation or display. After students in each group presented their team-work presentations in class, the teachers graded the students\u0026rsquo; presentations into 5 criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical \u003c/strong\u003e\u003cstrong\u003eanalysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe pre- and post-class-test scores, and the first- and last-day-test scores were statistically compared by using paired \u003cem\u003et\u003c/em\u003e-test at the significance level of\u0026nbsp;0.05. One-way analysis of variance (ANOVA) was used to compare the average scores among different groups or teaching methods. All data analyses were performed using SPSS 20.0 statistical software (SPSS Inc., Chicago, IL, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eBaseline data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 100 students, 50 male and 50 female, aged from 22 to 28 years old, were recruited. The following information was collected from the student record department of the university: 1) The admission scores for the medical college were collected and no significant difference was observed in the admission scores among four groups (\u003cem\u003eF\u003c/em\u003e=0.520, \u003cem\u003eP\u003c/em\u003e=0.669), 2) The final grade for all curricula, which are provided as a standard numerical grade (SNG) on a scale from 0 to 100, including the following subjects: Obstetrics and Gynecology, Pediatrics, Psychiatry, Neurology, Emergency Medicine, Disaster Medicine, Otolaryngology Head and Neck Surgery, Anesthetics, Dermatovenerology, Internal Medicine, Surgery, and Ophthalmology, and there was no significant difference in the final grade for all curricula among four groups, 3) The final grade of ophthalmology theory did not significantly differ among four groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompletion rate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the 100 clinical medical students who took part in the ophthalmology trainee courses completed pre- and post-class tests in the integrated modular teaching provided by Zhongshan Ophthalmic Centre. All data were collected and analysed. Eight clinical teachers jointly completed the innovative teaching work. No complaints from the students were reported throughout the trainee process.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003cstrong\u003effectiveness of TBL and \"flipped classroom\" session\u003c/strong\u003e\u003cstrong\u003es\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe average scores of pre- and post-class tests in both TBL and \"flipped classroom\" sessions were calculated and analyzed. The pre- and post-class test scores in each group were statistically compared by using a paired \u003cem\u003et\u003c/em\u003e\u003cem\u003e-\u003c/em\u003etest. The total students' scores in each group were improved in the post-class test during both TBL and \"flipped classroom\" sessions (TBL: \u003cem\u003et\u003c/em\u003e=12.208, \u003cem\u003eP\u003c/em\u003e=0.000; \"flipped classroom\": \u003cem\u003et\u003c/em\u003e=37.822; \u003cem\u003eP\u003c/em\u003e=0.000) (Figure 1). The students\u0026rsquo; questionnaires were collected and their acceptance of these two new teaching methods was evaluated by calculating the number of students who responded with \u0026ldquo;agree\u0026rdquo; (Table 2). Among them, 70% of the students believed that these two teaching methods were beneficial for learning. The details and survey questions of student perceptions regarding various teaching methods are presented in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eComprehensive evaluation of the integrated modular teaching\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA comprehensive evaluation was conducted among all enrolled students by the first-day-test and last-day-test, which were organized before and after the integrated modular teaching with innovative teaching methods for 1 week. The average scores of each group, including the first-day-test and last-day-test, are presented in Figure 2. The first-day-test scores did not significantly differ among four groups by ANOVA test. The paired \u003cem\u003et\u003c/em\u003e\u003cem\u003e-\u003c/em\u003etest was used to compare the average score of first-day-test before the trainee courses and the total last-day-test score after the courses. The total last-day-test score was significantly improved (\u003cem\u003et\u003c/em\u003e=3.288, \u003cem\u003eP\u003c/em\u003e=0.001). By comparing the first-day-test and last-day-test scores, 19 students who had outstanding performance with ranking increased by more than 10 in the post-class test were screened. There students were then assigned into the improvement group in Figure 2, and the daily performance of these outstanding students was assessed to discuss whether they paid more attention in the classroom. However, they did not have higher average scores in daily performance than other students (\u003cem\u003et\u003c/em\u003e=0.469, \u003cem\u003eP\u003c/em\u003e=0.654). Most students were satisfied with the innovative teaching methods based on their answers to the questionnaire. A small number of students did not agree with the effectiveness of these new teaching methods, even if their test results were improved.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith the introduction and development of multimedia, computers and the internet in this information era, modern technologies can increasingly be used to replace the previous teaching methods and to usher in an era of rich teaching resources. The applications of modern technology and abundant public learning resources have promoted a reform from previous teacher-centred to student-centred teaching modes. Student-centred teaching can cultivate higher-order thinking, problem solving and critical analysis, and provide feedback on the learning process [17]. Learning is a complex process, and previous studies have confirmed that increasing active learning can produce a better learning result [18,19]. Recently, a variety of student-centred teaching methods have been conducted in medical teaching [10,20].\u003c/p\u003e\n\u003cp\u003eThe trainee courses of ophthalmology are established to improve students' knowledge in clinical practice, to guide them to integrate knowledge in theory with practice, and eventually to attract more outstanding students to the ophthalmology profession. All the teaching modules we are conducting are based on problem-solving.\u003c/p\u003e\n\u003cp\u003eIn this study, the effectiveness of each major innovative teaching method was evaluated by pre- and post-class tests for 100 medical students. The post-class scores of all students were improved. A majority of students were satisfied with the innovative teaching methods based on their answers to the questionnaire. Because each student has preferred learning habits and thinking modes, it is understandable that a small number of students do not agree with the effectiveness of these new teaching methods, even if their test results are improved. Overall, integrated teaching modes are appropriate for the learning habits of most students.\u003c/p\u003e\n\u003cp\u003eA comprehensive evaluation of integrated teaching modes was conducted by comparing the pre- and post-class test scores. Most students presented with significant improvement in the post-class test scores, suggesting that this multi-mode teaching method is highly effective in ophthalmology trainee courses. In previous teaching styles, the teacher-centred teaching method forces students to passively accept knowledge. The grades of students depend on how they listen in the classroom and review the materials after class. Diligent students can often obtain better grades. Therefore, different learning attitudes among students may make an enormous difference in the degree of knowledge they master. However, these innovative teaching methods are implemented based on student-centred teaching, which stimulates autonomous and active learning of the students. These curricula were designed to comprise different modules using a variety of teaching methods, which can enhance learning interests, reduce boredom and increase the acceptance by students.\u003c/p\u003e\n\u003cp\u003eThe multi-mode teaching methods in this study included a \"flipped classroom\" session, consisted of simulation scenario teaching, case-based learning, and other methods that improved the autonomous learning capability of the students, which plays a pivotal role in the life-long career growth of medical students [21]. Therefore, the education of medical students is not only involved with teaching professional knowledge but also how to take the initiative to study and how to use the educational platforms provided by modern science and technology. In addition, the teamwork capability is of significance for medical students because hospitals are workplaces based on teamwork [22]. The TBL method can teach students how to learn from each other and jointly progress in a team.\u003c/p\u003e\n\u003cp\u003eCompared with other medical subjects, ophthalmology is more closely associated with advanced science and technologies, such as the application of lasers, new materials, and optical instruments, which require ophthalmologists to maintain effective learning and to develop more autonomous learning than other specialists. Therefore, this teaching method might provide particular assistance for medical students who are determined to become ophthalmologists.\u003c/p\u003e\n\u003cp\u003eIn our study, the students\u0026rsquo; daily performance was analysed. All students had worse daily performances in TBL session than the \"flipped classroom\" and case-based learning sessions, which was consistent with the questionnaire results. TBL had a lower degree of recognition. A total of 19 students obtained an increase in academic performance by more than 10 points in the post-class test, whereas their daily performance in class or attendance were not better compared with other students, probably prompting that all students have excellent class performance when autonomous learning awareness is triggered. This situation differs from previous learning modes because greater efforts have been made throughout the whole learning process, and more significant improvement has been obtained. Nevertheless, whether the learning effect will decrease over time remains elusive. Hence, these students should be followed up to examine their learning ability and the durability of this method in subsequent investigations.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn the present study, the integrated modular teaching is an effective teaching method and appreciated by medical college students in ophthalmology trainee courses. It deserves to be introduced to the trainee or teaching process in other medical specialized subjects.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTBL, team-based learning; CBL, case-based learning; ANOVA, One-way analysis of variance\u003c/p\u003e"},{"header":"Declaration","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the procedures in this study were approved by the Institutional Review Board of Zhongshan Ophthalmic Center of Sun Yat-sen University (Ethic ID: 2016MEKY062). All subjects gave their written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u0026nbsp;\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 analysed 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.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Key R\u0026amp;D Program of China (2018YFC0116500), National Natural Science Foundation of China (No. 81770967, 81822010), the Science and Technology Planning Project of Guangdong Province (No.2017B030314025, 2018B010109008, 2019B030316012, 2019A070701006), And Guangdong Science and Technology Innovation Leading Talents \u0026nbsp;(No. 2017TX04R031) . The sponsors of the study played no role in the study protocol design, data collection, data analysis, data interpretation, manuscript preparation, or the decision to submit the manuscript for publication.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWX performed the collection of the data, and was a major contributor in writing the manuscript. YZ and YA were in charge of the teaching inspectorate and collected the\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; data. YC, ZH and ML analyzed and interpreted the data. CX, YJ and YY collected the data. YFY and HL designed the study protocol and collected the data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWalsh, K. E-learning in ophthalmology: where next? \u003cem\u003eIndian Journal of Ophthalmology\u003c/em\u003e. 2014; 62(12): 1178.\u003c/li\u003e\n\u003cli\u003eShah, M., et al. The state of ophthalmology medical student education in the United States and Canada, 2012 through 2013. \u003cem\u003eOphthalmology\u003c/em\u003e. 2014; 121(6): 1160-1163.\u003c/li\u003e\n\u003cli\u003eTsinopoulos, I.T., et al. Contribution of integrated teaching in the improvement of an undergraduate ophthalmology curriculum. \u003cem\u003eAdvances in Medical Education and Practice\u003c/em\u003e. 2014; 5: 433-437.\u003c/li\u003e\n\u003cli\u003eStrayer, J.F. How learning in an inverted classroom influences cooperation, innovation and task orientation.\u003cem\u003e Learning Environments Research\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e 2012; 15: 171-193.\u003c/li\u003e\n\u003cli\u003eBurgess, A.W., et al. Applying established guidelines to team-based learning programs in medical schools: a systematic review. \u003cem\u003eAcademic Medicine\u003c/em\u003e. 2014; 89(4): 678-688.\u003c/li\u003e\n\u003cli\u003eAhn, H. \u0026amp; Kim, H.Y. Implementation and outcome evaluation of high-fidelity simulation scenarios to integrate cognitive and psychomotor skills for Korean nursing students. Nurse Education Today. 2015; 35(5): 706-711.\u003c/li\u003e\n\u003cli\u003eKarthikeyan, K. \u0026amp; Kumar, A. Integrated modular teaching in dermatology for undergraduate students: A novel approach. \u003cem\u003eIndian Dermatology Online Journal\u003c/em\u003e\u003cem\u003e. \u003c/em\u003e2014; 5(3): 266-270.\u003c/li\u003e\n\u003cli\u003eKurien, G., et al. Can a multisensory teaching approach impart the necessary knowledge, skills, and confidence in final year medical students to manage epistaxis? \u003cem\u003eJournal of Otolaryngology - Head \u0026amp; Neck Surgery\u003c/em\u003e. 2013; 42: 51.\u003c/li\u003e\n\u003cli\u003eAltintas, L., et al. Modified use of team-based learning in an ophthalmology course for fifth-year medical students. \u003cem\u003eAdvances in Physiology Education\u003c/em\u003e\u003cem\u003e. \u003c/em\u003e2014; 38(1): 46-48.\u003c/li\u003e\n\u003cli\u003eShetty, S.R., et al. Case-based, team-based learning: a novel method for teaching orofacial syndromology to dental undergraduate students. \u003cem\u003eEducation for health (Abingdon, England)\u003c/em\u003e. 2015; 28(1): 112-113.\u003c/li\u003e\n\u003cli\u003eWong, T.H., et al. Pharmacy students' performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. \u003cem\u003eAmerican Journal of Pharmaceutical Education\u003c/em\u003e.2014; 78(10): 185.\u003c/li\u003e\n\u003cli\u003eAljarallah, B. \u0026amp; Hassan, M.S. Problem based learning (PBL) vs. Case based curriculum in clinical clerkship, Internal Medicine innovated Curriculum, Student prospective. \u003cem\u003eInternational Journal of\u0026nbsp;Health\u0026nbsp;Sciences (Qassim)\u003c/em\u003e. 2015; 9(2): 147-152.\u003c/li\u003e\n\u003cli\u003eMcMullen, I., et al. Team-based learning for psychiatry residents: a mixed methods study. \u003cem\u003eBMC Medical Education\u003c/em\u003e. 2013; 13: 124.\u003c/li\u003e\n\u003cli\u003eYang Y, Xu C-C, Jia Y, et al. Flipped classroom approach to ophthalmology clerkship courses for Chinese students of eight-year program. Annals of Eye Science. 2017;2(7).\u003c/li\u003e\n\u003cli\u003eHuang, Z., et al. Modified team-based learning in an ophthalmology clerkship in China. \u003cem\u003ePLoS One\u003c/em\u003e. 2016; 11(4): e0154250.\u003c/li\u003e\n\u003cli\u003eParmelee D.X. \u0026amp; Michaelsen L.K. Twelve tips for doing effective Team-Based Learning (TBL). Med Teach. 2010; 32(2): 118\u0026ndash;122.\u003c/li\u003e\n\u003cli\u003eGleason, B.L., et al. An active-learning strategies primer for achieving ability-based educational outcomes. \u003cem\u003eAmerican Journal of Pharmaceutical Education\u003c/em\u003e. 2011; 75(9): 186.\u003c/li\u003e\n\u003cli\u003eHarakuni, S.U., et al. Effectiveness of team-based learning in microbiology: a non-randomized control study. \u003cem\u003eEducation for health (Abingdon, England)\u003c/em\u003e. 2015; 28(1): 41-44.\u003c/li\u003e\n\u003cli\u003eJensen, J.L., et al. Improvements from a flipped classroom may simply be the fruits of active learning. \u003cem\u003eCBE-Life Science Education\u003c/em\u003e. 2015; 14(1): ar5.\u003c/li\u003e\n\u003cli\u003eSteedman, M., et al. Multimedia learning tools for teaching undergraduate ophthalmology: results of a randomized clinical study. \u003cem\u003eCanadian Journal of Ophthalmology\u003c/em\u003e. 2012; 47(1): 66-71.\u003c/li\u003e\n\u003cli\u003eDornan, T. Workplace learning. \u003cem\u003ePerspectives on\u0026nbsp;Medical\u0026nbsp;Education\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e 2012; 1(1): 15-23.\u003c/li\u003e\n\u003cli\u003eWatts, B., et al. Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems. \u003cem\u003ePopulation Health Management\u003c/em\u003e. 2016; 19(4): 232-239.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cspan style=\"font-size: 12px; font-family: Helvetica; color: rgb(0, 0, 0);\"\u003eTable1 Modular teaching on topics of ophthalmology and teaching methodologies.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"margin-left: -21.3pt; border-collapse: collapse;\" width=\"1037\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 15.0pt;\"\u003e\n \u003ctd style=\"width: 148.9pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eTeaching methodology\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eModule\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 359.8pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eDescription\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd rowspan=\"5\" style=\"width: 148.9pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eLecture\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eAnatomy of the eye\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"5\" style=\"width: 359.8pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eSystematic introduction to sensitize and familiarize the student with certain concepts and clinic features through PPT\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eOphthalmologic examination\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eLids and lacrimal apparatus\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eCataract and refractive error\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eRetina and ocular disorders associated with systemic disease\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd rowspan=\"2\" style=\"width: 148.9pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eVideo demonstration\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eAnatomy of the eye\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 359.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eVideo demonstration of all the steps of a procedure\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.8pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.8pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eRetina and ocular disorders associated with systemic disease\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd rowspan=\"2\" style=\"width: 148.9pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003ePractice\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eAnatomy of the eye\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 359.8pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eBasic ophthalmic examination practice and dissecting a pig eyeball\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 11.7pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 11.7pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eOphthalmologic examination,Cataract and refractive error\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 28.5pt;\"\u003e\n \u003ctd rowspan=\"2\" style=\"width: 148.9pt; padding: 0in 5.4pt 0in 5.4pt; height: 28.5pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003ePhoto demonstration\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; padding: 0in 5.4pt 0in 5.4pt; height: 28.5pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eLids and lacrimal apparatus\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 359.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 28.5pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eA series of images of various manifestations of the disease were demonstrated by projection. The students had to describe what they saw and attempt to explain the correlation with the clinical condition\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 16.65pt;\"\u003e\n \u003ctd style=\"width: 269.3pt; padding: 0in 5.4pt 0in 5.4pt; height: 16.65pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eRetina and ocular disorders associated with systemic disease\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 58.05pt;\"\u003e\n \u003ctd style=\"width: 148.9pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 58.05pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eCase-based learning (CBL)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 58.05pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eConjunctivitis and uveitis, Keratitis\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 359.8pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 58.05pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eTypical cases from outpatient clinic or hospital ward were demonstrated. The students had to inquire about medical history, collect clinical examination information and attempt the diagnosis. A summary of key learning points was given by the clinical teacher\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 42.6pt;\"\u003e\n \u003ctd style=\"width: 148.9pt; padding: 0in 5.4pt 0in 5.4pt; height: 42.6pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eSimulation scenario teaching\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; padding: 0in 5.4pt 0in 5.4pt; height: 42.6pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eGlaucoma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 359.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 42.6pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eClinic teachers and students play patients with ocular disease and doctors in a scenario, o, respectively. Students acted as doctors and asked questions. A summary of key learning points was given by the clinical teacher.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 46.05pt;\"\u003e\n \u003ctd style=\"width: 148.9pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 46.05pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eFlipped classroom\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 46.05pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eOcular trauma\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 359.8pt; background: #D9D9D9; padding: 0in 5.4pt 0in 5.4pt; height: 46.05pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eSome problems were raised from the learning material by the teacher. The students had to self-study all content, answer all questions and provide new questions for the discussion in class.\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 21.3pt;\"\u003e\n \u003ctd style=\"width: 148.9pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 21.3pt;\" width=\"199\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eTeam-based learning (TBL)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 269.3pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 21.3pt;\" width=\"359\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eBlindness\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 359.8pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 21.3pt;\" width=\"480\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eStudents of each group had to complete a presentation associated with the given topic.\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"line-height: 200%;\"\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eTable2 Survey of Student Perceptions Regarding Two Teaching Methods\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse;\" width=\"617\"\u003e\n \u003ctbody\u003e\n \u003ctr style=\"height: 15.75pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; border: none; border-top: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 208.25pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt; height: 15.75pt;\" width=\"278\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eNumber of Strongly Agree/Agree Responses (%)\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 14.25pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eSurvey Question\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eFlipped classroom\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt; height: 14.25pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eTeam-based learning\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt helped me to reach a higher level of knowledge\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e93.30\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e89.41\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt was an effective, motivating learning process\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e89.90\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e83.53\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt was well organized\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e100.00\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e94.12\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt challenged me to give my best\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e95.00\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e81.18\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt had a positive impact on my learning attitudes\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e93.20\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e78.82\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 13.5pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eI was satisfied with this teaching method\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e89.80\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; padding: 0in 5.4pt 0in 5.4pt; height: 13.5pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e75.29\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr style=\"height: 15.0pt;\"\u003e\n \u003ctd style=\"width: 254.7pt; border: none; border-bottom: solid windowtext 1.0pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"340\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003eIt should be offered more frequently\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 97.8pt; border: none; border-bottom: solid windowtext 1.0pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"130\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e81.40\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 110.45pt; border: none; border-bottom: solid windowtext 1.0pt; background: #BFBFBF; padding: 0in 5.4pt 0in 5.4pt; height: 15.0pt;\" width=\"147\"\u003e\n \u003cp\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size: 12px;\"\u003e\u003cspan style=\"font-family: Helvetica;\"\u003e75.29\u0026nbsp;\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style=\"line-height: 150%;\"\u003e\u003cspan style=\"font-family: Helvetica; font-size: 12px; color: rgb(0, 0, 0);\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","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":"Ophthalmology, Teaching, Effectiveness, Problem-based, Trainee course","lastPublishedDoi":"10.21203/rs.2.12632/v3","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.2.12632/v3","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003eBackground: \u003c/em\u003eBefore attending ophthalmology trainee courses in Zhongshan Ophthalmic Centre, the medical students from Sun Yat-sen University had finished two years of premedical education after the six-year medical courses including basic medical courses, clinical medical courses, clerkship, and research training in medical college. Integrated modular teaching using different problem-based teaching methods in ophthalmology was designed by the teaching steering committee of Zhongshan Ophthalmic Centre. This study aimed to evaluate the effectiveness and satisfaction scales of the integrated modular teaching among the trainee students. \u003c/p\u003e\u003cp\u003e\u003cem\u003eMethods: \u003c/em\u003eA total of 100 medical students attending ophthalmology trainee courses in Zhongshan Ophthalmic Centre were enrolled and randomly allocated into 4 groups according to the teaching arrangement. The trainee courses consisted of several sessions delivered in multiple methods, such as \"flipped classroom\" session and team-based learning session. The pre- and post-class tests were delivered to evaluate the effectiveness of the integrated modular teaching. The satisfaction survey questionnaire was collected from all participants to investigate the degree of satisfaction. \u003c/p\u003e\u003cp\u003e\u003cem\u003eResults: \u003c/em\u003eCompared with the first-day-test score, the total last-day-test score was significantly improved by a paired \u003cem\u003et-\u003c/em\u003etest (\u003cem\u003et\u003c/em\u003e=3.288, \u003cem\u003eP\u003c/em\u003e=0.001). Nineteen students obtained a significant improvement in ranking increased by more than 10 in the last-day-test, whereas they failed to obtain a higher average score for daily performance than other students (\u003cem\u003et\u003c/em\u003e=0.469, \u003cem\u003eP\u003c/em\u003e=0.654). According to the participant satisfaction questionnaires, these innovative teaching methods were considered as effective and satisfactory. \u003c/p\u003e\u003cp\u003e\u003cem\u003eConclusions:\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eIntegrated modular teaching in ophthalmology trainee courses is effective and widely recognized by the medical college students.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Evaluationof Integrated Modular Teaching in Chinese Ophthalmology Trainee Courses","msid":"","msnumber":"","nonDraftVersions":[{"code":3,"date":"2020-05-15 14:40:31","doi":"10.21203/rs.2.12632/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accept","date":"2020-05-11T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-04-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-04-29T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-08-05T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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}},{"code":2,"date":"2020-02-28 06:06:00","doi":"10.21203/rs.2.12632/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-04-21T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-04-12T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nDear colleagues,\n\nI appreciate the work that has been done to revise the manuscript, and acknowledge with thanks the integration of the reviewer recommendations. The paper reads much more clearly now.\nThere are only minor English language errors remaining to be corrected.\nI note that you used an English native expert, but although the draft has been significantly improved, I'm afraid they still missed some things:\n\nSyntax corrections:\n\nL9: \"two years of\"\nL23: t values at end of sentence\nL24: \"obtained\"\nL25: \"whereas they\"\nL29: delete \"widely recognized\", replace with \"appreciated\"\nL35: \"the\" teaching style …\nL36: delete \"is not interesting and efficient enough\", replace with \" may lack efficiency and student interest\".\nL43: \"(an inverted …)\"\nL85-86: Shouldn't this sentence about student perceptions be in the Results section?\nL89: \"of\" integrated ….\nL100: delete \"the selected …\" line as not relevant to the protocol\nL102: delete \"public\"\nL136: replace \".\" with \",\"\nL140: replace \".\" with \",\" insert \"and there was no …\"\nL141: replace \".\" with \",\"\nL169: Finish sentence at 'screened'. Delete 'who were'. New sentence: \"These students were then\" assigned …\nL189: replace 'books' with \"theory\"\nL190\" replace \"specialists' with \"profession\".\nL222: New paragraph from \"Compared..\"\nL227: New paragraph from \"In our..\"\nL234: \"modes\"\nL243: delete \"widely recognized\", replace with \"appreciated\"\n\nThanks again for the opportunity to review your research, and I hope your innovative teaching continues to flourish!\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please publish my name with my report.**\n"},{"type":"reviewerAgreed","content":"","date":"2020-03-25T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-03-13T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-02-27T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-02-26T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-02-26T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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}},{"code":1,"date":"2019-08-12 01:59:54","doi":"10.21203/rs.2.12632/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-01-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-01-26T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **No**\n* Does the work include the necessary controls?: **No**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Needs some language corrections before being published**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nThe authors report on \"integrated modular teaching\" at their institution.\n\nGrammatical editing is necessary.\n\nBackground, 1st paragraph, line 12-13: \"conventional teaching style\" should be described. What does this mean?\n\nMethods: The authors state that a total of 10 teaching modules were conducted. They describe 2 types of teaching - flipped classroom and team-based learning. It is unclear to me how the 10 modules and the types of teaching are related? Were half the 10 modules taught with one technique and the others with the second technique?\n\nResults: It is unclear to me what differentiated the 4 groups in terms of the teaching? Were the teaching interventions different?\n\nConclusion:\n\nFigure 1 - I don't understand the relevance of this figure? It seems redundant to the text. One could simply say there were no differences in these areas between the groups?\n"},{"type":"reviewerAgreed","content":"","date":"2020-01-20T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2019-11-01T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I recommend additional statistical review**\n* Quality of written English: **Not suitable for publication unless extensively edited**\n* Declaration of competing interests: **I declare that I have no competing interests**\n\nComments to Author:\n---\nDear Colleagues,\n\nThank you for the opportunity to review your article. I would like to congratulate your team on an important area of research and an innovative approach to dealing with it. The study itself has merit and I believe should eventually be published. However there are major deficiencies that need to be addressed. The main points are outlined here and more detailed analysis presented below.\n\n1. Many if not most conclusions are not supported by adequate data. There is no detailed statistical analysis presented, although results are mentioned. The work apparently has been done so you should present as much as possible to allow the reader to assess the veracity of the research.\n2. Much of the interpretation of the data is confusing. For example the second half of the Comprehensive Evaluation in the Results (L44 on) is difficult to follow and needs to be logically explained. It is unclear for example what 'ranking ahead' in a subgroup means. Another example is the difference in scoring axes in Fig.2, which is not explained either.\n3. The discussion is scarce on references and heavy on anecdote and opinion. It needs to be far more literature based, and relevant to the Results section. There were also some statements introduced here for the first time, which should be in the Results section.\n4. The conclusion is over-reaching and goes beyond the research presented.\n5. The standard of English is poor. Over a dozen simple errors in grammar and syntax were found on just the first 2 pages; I had to stop counting after that as they were too numerous. I would suggest a professional English language prrof-reading service to help you in managing this.\n\nAs stated the subject matter is significant and I hope you can address these issues.\nRegards,\nAA\n\nDetailed critique:\n\nTitle: Space between 'Evaluation' and 'of'\n\nAbstract\n\nL22- \"…. were receiving…\" not \"was\"\nL26- Please specify how many students per small group\nL40- \"paired t test\" not \"pair\"\nL57- delete \"… using in trainee courses..\"\nL59- This sentence does not make sense. What does \"ranking ahead of more than 10\" mean; is this a final score, a class rank or some other metric? Also please clarify the rest of the sentence regarding higher average daily scores; as it is not clear what this relates to.\n\nMethods\n\nP2-L5 \".. based ..\" not \"basing\"\n-L14 \" \".. is displayed..\" not \"was\"\n-L16 delete \".. of contents..\"\n-L19 insert \"… of single eye redness..\"\n-L27 should be ..\"photophobia\" not \"phobia\"\n-L27 What are \"water cracks in the lens\" this is not standard clinical terminology\nP3-L25 correct spelling of \"discuss\"\n-L40 when referencing your own papers please just refer to it as a standard reference; the details of where it was published and the online reference are not required\n-L52 same issue\n\nResults\n\nP1-L26- Does this 'final grade of ophthalmology\" refer to an already completed course, separate to the one being studied in this paper? This needs to be clarified.\n-L26- This final grade is said to be \"significantly different\" but Fig.1 does not show this. Need data to justify this statement, and to explain what it is different from.\n-L33- Need to see the data\nP2-L44 this section is confusing and needs to be rewritten in a logical fashion. It is not clear what is being claimed.\n-L54 The Results section is not the place for judgement about the success or otherwise of the study- this is for the Discussion section.\n-L58 - see comment for Abstract L59 above\n\nFigures\n-Need error bars and confidence intervals\nFig.2- I note the y axis scale are not the same for the TBL and FC cohorts. Please explain.\n\nDiscussion\n\nP1-L38 This is a useful section and I understand the message, however the manner is highly informal and anecdotal. While compelling, it would be strengthened by some references. Also one cannot include new results in the Discussion; ophthalmology may well be a 'hot topic' now but you need to have data or statements in the Results section to back this up.\n\nMuch of this whole section is opinion with few references or facts; needs to be an academic assessment not an opinion piece.\n\nConclusion\n\nL29- Cannot extrapolate one study to the whole country; specify the one college studied. Also we have no measuring the admission scores or comparing them, so cannot claim they are outstanding without this information. Delete this sentence as it is unverified and besides does not speak to the main focus of this research.\n\nEthics approval- this needs to be noted in the Methods section, along with the statement about student informed consent.\n\n"},{"type":"reviewerAgreed","content":"","date":"2019-10-22T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2019-09-22T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2019-08-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2019-08-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2019-08-04T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2019-07-31T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"c701c0d3-baf2-4a8b-8dcc-1914aadd8e4c","owner":[],"postedDate":"May 15th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":101103,"name":"Educational Philosophy and Theory"},{"id":101104,"name":"Ophthalmology"}],"tags":[],"updatedAt":"2021-08-06T02:06:39+00:00","versionOfRecord":{"articleIdentity":"rs-3376","link":"https://doi.org/10.1186/s12909-020-02073-w","journal":{"identity":"bmc-medical-education","isVorOnly":false,"title":"BMC Medical Education"},"publishedOn":"2020-05-19 00:00:00","publishedOnDateReadable":"May 19th, 2020"},"versionCreatedAt":"2020-05-15 14:40:31","video":"","vorDoi":"10.1186/s12909-020-02073-w","vorDoiUrl":"https://doi.org/10.1186/s12909-020-02073-w","workflowStages":[]},"version":"v3","identity":"rs-3376","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"identity":"rs-3376","version":["v3"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}