Advanced team-based learning in clinical probation: improving initiatives for learning and team spirit of fourth year medical students

Advanced team-based learning in clinical probation: improving initiatives for learning and team spirit of fourth year medical students | 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 Advanced team-based learning in clinical probation: improving initiatives for learning and team spirit of fourth year medical students Xiaohong Zhang, Ziying Lei, Yusheng Jie, Yuankai Wu, Yun Zhou, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3361469/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Team-based learning (TBL) is widely used in preclinical medical curriculum. The aims of this study were to investigate the TBL teaching model in clinical probation and evaluate its teaching effectiveness in case discussion, compared with case-based learning (CBL). Fourth-year medical students who participated in clinical probation of infectious diseases were randomly distributed into the TBL and CBL groups. Each student anonymously completed teaching effectiveness evaluation forms after case discussions, and after the final examination. From August to September 2015, 100 students were enrolled. Both groups had clear teaching objectives and easy to follow teaching procedures. A higher percentage of students in the TBL group agreed that TBL contributed to the initiatives for preview and motivated case discussion, team spirit, and collaboration; but differences between the 2 groups were not significant ( all P > 0.05). From December 2016 to April 2018, 239 students participated in TBL and 213 students in CBL. Compared with the CBL group, TBL received significantly higher scores of the above items (all P < 0.05), and also significantly higher scores with respect to the capacity of combining theory with clinical practice, and improved teacher-trainee interactions and practical problem-solving ability. The final examination scores of the TBL group were significantly higher than those of the CBL group ( P = 0.021). In conclusion, TBL is more effective for improving medical student initiatives for preview and motivated case discussion, team spirit, and collaboration. Continuing efforts positively impacted student assessment of TBL and increased student appreciation for it. Team-based learning (TBL) teaching effectiveness clinical probation case-based learning (CBL) Figures Figure 1 1 Introduction Team-based learning (TBL) was first proposed by Professor Michaelsen in 2002, and expected to provide the benefits of small-group learning within large classes [ 1 ]. It usually includes a number of steps [ 2 ]. Before beginning the TBL sessions, students in the study group are divided into several teams, each consisting of 5–7 individuals. These teams remain the same for all TBL sessions. The students are informed about the topic in advance. During the class, students take an individual readiness assurance test (iRAT), followed by a group readiness assurance test (gRAT). A case scenario is presented for team discussion based on the knowledge they have gained (application exercise). The session concludes with peer feedback among the teams. Since its introduction, TBL has been widely used in preclinical medical curriculum in many countries [ 2 – 4 ]. Previous studies [ 2 , 4 , 5 ] have suggested that TBL promotes self-directed learning, enhance students’ adaptability in problem-solving situations, and cultivates a team spirit, rather than simply memorizing and reproducing information. We applied TBL in theoretical classes of infectious diseases at Sun Yat-sen University (SYSU) from 2012 to 2013. Within limited class time, it was difficult for teachers to conduct TBL in a large class in which there were more than 10 TBL groups. We found the teaching effectiveness of TBL was limited, similar to the findings of Whillier et al. [ 6 ] and Burgess et al. [ 7 ]. Moreover, Minges et al. [ 8 ] and Burgess et al. [ 9 ] supported that TBL focused on how to use theoretical knowledge. As such, TBL might be more suitable for students who have obtained basic theory, and urgently need to translate basic knowledge into clinical application. Clinical probation is a special stage of higher medical education in China. During this period, under the supervision of an attending physician, medical students begin to learn how to apply theoretical knowledge in clinical practice. It is also a particularly ‘critical phase’ that affects the professional development, retention, and career success of young health professionals. Case-based learning (CBL) is the most commonly used teaching model, in which medical students work in small collaborative groups to discuss problems that are presented in a case scenario [ 3 ]. Compared to TBL, CBL takes less time because the teacher can guide students to the key points of case and clinical problem-solving [ 10 ]. Burgess et al. [ 11 ] also suggested that CBL was more relevant as students move towards clinic training. However, many studies [ 2 , 3 , 12 ] have reported that students felt TBL was centered on teaching, but ignored student learning initiatives, which resulted in passive learning and the lack of hands-on practical training. Carrasco et al. [ 13 ] reported that prior experience of TBL could improve TBL iRAT scores. Aboregela et al. [ 14 ] believed that TBL is more beneficial to students with respect to practical sciences, because group peer teaching enhances the sense of competition. A pressing challenge in the modern medical education system is how to bridge the gap between a basic theoretical curriculum and clinical practice. Burgess et al. [ 9 ] and Singh et al. [ 15 ] highlighted an active and engaging learning strategy, and advised using randomized controlled trials to assess the effectiveness of various learning strategies. The aims of this study are to investigate the TBL teaching model in clinical probation, and evaluate its teaching effectiveness of case discussion, compared with CBL. 2 Methods 2.1 Study design The study was hosted by the Department of Infectious Diseases, Third Affiliated Hospital of SYSU, whose design is demonstrated in Fig. 1 . From February to July in 2015, teachers learned TBL theory and mastered its teaching skills [ 2 , 4 , 5 ]. In SYSU, the clinical probation syllabus of infectious diseases for undergraduate medical education includes the topics of the differential diagnosis and treatment of jaundice of unknown origin, viral hepatitis, infectious fever with multiple organ dysfunction, central nervous system infection, and parasitic diseases. Cases related to the above topics were selected, and tests were designed. Teachers also designed teaching effectiveness evaluation forms, and each item had 4 possible answers: strongly agree, agree, neutral, and disagree. The participating medical students were fourth year students at SYSU, had completed the preclinical curriculum of infectious diseases, and were ready to participate in clinical probation. The students were randomly distributed into the TBL and CBL groups. And in each group, they were divided into multiple small teams of 5–7 individuals. These teams remained the same for all sessions. Two days before the case discussion, students were informed of the topic of the case discussion, and instructed to review relative theoretical knowledge by themselves. Teachers selected 3 cases for each topic. On the first day of the TBL session, students spent 25–30 minutes inquiring about the medical history, and performing a physical examination on case 1. The teacher spent about 10 minutes reviewing the medical data of case 2. On the second day, students spent 20–25 minutes inquiring about the medical history of case 3, and performing a physical examination. Subsequently, students answered iRAT (answer 5 questions in 15 minutes), followed by gRAT (discuss 10 questions in 35 minutes) related to the 3 cases. The iRAT and gRAT contained 3 and 6 questions, respectively, to evaluate the ability of students to apply theoretical knowledge in clinical practice. Finally, students could express what they gained during the final application exercise (15 minutes). Throughout the TBL session, the teacher controlled the discussion time, and instructed students to strengthen their clinical thinking on the selected topic. There were the same number of students in the CBL group as in the TBL group. Students were also given 25–30 minutes to inquire about the medical history and perform physical examinations on the cases. The teacher then spent 60 minutes directing the students to discuss the problems of the cases. Each student anonymously completed teaching effectiveness evaluation forms after the case discussion. We collected and analyzed the TBL and CBL course activity and performance data, as well as the final exams score of each student. 2.2 Project modification From September to November in 2016, we analyzed teaching effectiveness evaluation forms and final examination scores of the TBL and CBL groups conducted in 2015, and re-studied TBL theory [ 2 , 4 , 5 ]. In addition, we summarized our teaching experiences from 2015 and strengthened expression, questioning, and organization of the TBL and CBL sessions. Teaching topics were chosen that strengthened the differential diagnosis and treatment of infectious fever in multiple organs. We re-selected and added related cases to clinical probation. Tests were also re-designed, with 4 and 8 questions related to clinical practice in the iRAT and gRAT, respectively. In addition, time allocation of the TBL sessions was optimized. On the second day, students spent 15 minutes inquiring about the medical history and performing a physical examination on case 3. Then students answered iRAT (10 minutes) followed by gRAT (35 minutes) questions. Finally, students could express what they gained at the final application exercise (30 minutes). To validate the results of teaching effectiveness, we enrolled more students in the study performed from December 2016 to April 2018 than in the prior study. 2.3 Statistical analysis Descriptive statistical analysis, the chi-square test and t-test were used to analyze the data. Statistical analyses were performed using IBM® SPSS® version 22.0 software (Armonk, NY, USA). In all analyses, a value of P < 0.05 was considered significant. 3 Results Course activity and performance of the students in 42 TBL teams and 40 CBL teams (5-7 students/team) were measured. Student theoretical examination scores before clinical probation of infectious diseases are shown in Table 1. There was no significant difference between the 2 groups (both, P >0.05). Eligible teaching effectiveness evaluation forms and final examination scores were collected from all students. 3.1 Comparison between TBL and CBL in 2015 From August to September 2015, 100 students were enrolled in the study. They were randomly distributed into the TBL and CBL groups, with 50 students in each group. The results of teaching effectiveness evaluation forms are shown in Table 2, and student final examination scores are shown in Table 4. There were no significant differences between the 2 groups (all P >0.05). However, a higher percentage of students in the TBL group indicated that the teaching model contributed to the initiative for preview, and motivated case discussion, team spirit, and collaboration. 3.2. Comparison between TBL and CBL from December 2016 to April 2018 A total of 239 students participated in TBL and 213 students were in CBL. As shown in Table 3, ratings of the TBL and CBL were similar with respect to the following items (all P > 0.05): (i) teaching objectives are clear; (ii) key points of session topics are highlighted by tests; (iii) critical thinking is emphasized; (iv) the teaching procedure is easy to follow. However, the TBL group scored the other 6 items were significantly higher than that of CBL group (all P < 0.05). Furthermore, the scores of the TBL group were also significantly higher than those of the CBL group ( t = 2.310, P = 0.021) in final exams. However, the mean difference was small (85.8 vs. 84.8) (Table 4). 4 Discussion It is well known that the success of medical education depends on how to combine theoretical education with clinical training [ 9 , 12 ]. We optimized the TBL model in case discussions during the clinical probation of infectious diseases from 2015 to 2018 and compared with CBL. Between the TBL and CBL groups, no significant difference in students’ score of theoretical exams before clinical probation (Table 1 ). In our study, fourth-year medical students indicated that both the TBL and CBL teaching procedures were easy to follow. The 2 teaching models had clear teaching objectives, and emphasized critical thinking. The key points of session topics were highlighted by tests. Furthermore, our results supported that TBL more effectively improved students’ initiatives for preview, and motivated case discussion, team spirit, and collaboration. Significant differences were observed between TBL and the CBL group (Table 3 ) (all, P < 0.05). The results also showed that the success of TBL substantially relied on preparation based on instructor-assigned materials before the TBL session, which is consistent with the findings of Burgess et al. [ 7 ]. Being informed about the topics days before discussion, students had sufficient time to preview related theories. Because iRAT and gRAT require students to apply the knowledge acquired in preparation, problems, and clinical scenarios, TBL further promoted active learning before the session. Selected cases and iRAT/gRAT questions were closely related to the teaching topic, which helped to train differential diagnosis thinking and provided more engagement during class and more responsibility for their own learning. Lochner et al. [ 16 ] and Chen et al. [ 17 ] also thought that performing individual and group assurance tests with immediate feedback in TBL encourages students to prepare themselves before class, and contributes to case discussion. Student performance and perception were improved by the implementation of TBL. Moreover, teams remained the same for all TBL sessions, and gRAT indicated improved team spirit and collaboration. On the other hand, in 2015 there were no significant differences in final examination scores between the 2 teaching models (Table 4 ). This may be because there were only 100 fourth-year medical students enrolled, with 50 students in each group. As TBL was used for the first time for case discussion in clinical probation of infectious diseases, we believe the experience of teachers was insufficient in the initial stage of the study. Rezende et al. [ 18 ] reported that students did not attain better scores after TBL as compared to traditional lectures. However, Yan et al. [ 19 ] reported TBL enhanced examination scores. Based on the aforementioned information, we did not think the stud of 2015 provided a sufficient trial of TBL. Therefore, in the study from December 2016 to April 2018, there were 239 students in the optimized TBL model group, and 213 students in the CBL group. As shown in Table 4 , the final examination scores of students in the optimized TBL model group were significantly higher than those of the students in the CBL group ( t = 2.310, P = 0.021). This finding is consistent with that reported by Carrasco et al. [ 13 ]. The assessment incentives and methods used in TBL results in student performance that better predicts performance on summative examinations. Meanwhile, we also noticed that the mean difference was small between the 2 groups (85.8 vs. 84.8) (Table 4 ). This further confirmed that continuing these efforts positively impacted student assessment of TBL as a process, and increase student appreciation for TBL. Being better prepared for class, more engaged during class, and more responsible for their own learning were encouraged. Students had a more positive perception of team and teamwork, which is consistent with the results of Burgess et al. [ 7 ] and Kibble et al. [ 20 ]. Carrasco et al. [ 21 ] also pointed out the importance of using different TBL grades and incentive structures so as to foster the development of well-rounded physicians. Students need long-term learning to improve their practical problem-solving ability. Our study extended beyond traditional teaching methods which center on teaching, but ignores students' learning initiatives. Although this was a single center and single discipline study, it is the first time TBL was used for case discussion in clinical probation of infectious diseases. Given this success in our department, we encourage that TBL is used more in the clinical training of different medical disciplines. More students, more accurate quantitative scores, and longer-term observation will be necessary to further evaluate TBL in the future. 5 Conclusions The results of this 3-year study support that TBL is more effective at improving students’ initiatives for preview, and motivated case discussion, team spirit, and collaboration. Continuing these efforts positively impacts student assessment of TBL as a process and increases student appreciation of it. Abbreviations TBL: team-based learning; iRAT: individual readiness assurance test; gRAT: group readiness assurance test; CBL: case-based learning; SYSU: Yat-sen University Declarations A cknowledgments We would like to thank all the participating medical students for their kind participation. Author contributions All authors participated in the study concept and design, data acquisition, analysis, and interpretation, critical revision of the manuscript for important content, and statistical analyses. XHZ and JL wrote the manuscript. XHZ, ZYL, and JL conducted the literature review and revised the manuscript. All authors read the final manuscript, and consent to this submission. f unding This study was supported by Higher Education Teaching Reform and Teaching Quality Project Fund of SYSU, numbers No 82000-16300010 in 2011 and 82000-31911107 in 2016. Data Availability The data are available from the Department of Infectious Diseases, Third Affiliated Hospital of SYSU, and the corresponding author upon reasonable request. Competing interests The authors declare no financial or non-financial interests related to this research. Ethics approval The local Institutional Review Board of Sun Yat-sen University waived ethics approval for this research because the study protocol was not deemed to represent biomedical or epidemiological research, and no personal data were used. The procedures complied with data-protection rules, and all data were anonymized prior to analysis. References Michaelsen LK. Team-based learning for health professions education：a guide to using small groups for improving learning. Herndon: Stylus Publishing. 2008: p.9-31. Parmelee D, Michaelsen LK, Cook S, Hudes PD. Team-based learning: a practical guide: AMEE guide no. 65. Med Teach. 2013;34(5):e275-87. https://doi.10.3109/0142159X.2012.651179. 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Tables Table 1 The comparison of the scores of theoretical exams before clinical probation between TBL and CBL groups Enrollment period TBL group CBL group t P n score n score August to September in 2015 50 77.1 ± 5.9 50 77.3 ± 6.7 -0.183 0.855 December 2016 to April 2018 239 77.0 ± 8.2 213 76.9 ± 8.4 0.690 0.490 a TBL: Team-Based Learning; CBL: Case-based learning. Table 2 The comparison of teaching effectiveness between TBL and CBL groups in 2015 Item TBL group [cases (%)] CBL group [cases (%)] χ2 P strongly agree agree neutral disagree strongly agree agree neutral disagree Teaching objectives are clear. 45 (90.0) 3 (6.0) 2 (4.0) 0 (0.0) 44 (88.0) 3 (6.0) 3 (6.0) 0 (0.0) 0.211 0.900 Key points of session topics are highlighted by tests. 44 (88.0) 2 (4.0) 3 (6.0) 1 (2.0) 43 (86.0) 3 (6.0) 2 (4.0) 2 (4.0) 0.745 0.863 Initiatives for preview are improved. 41 (82.0) 3 (6.0) 4 (8.0) 2 (4.0) 38 (76.0) 2 (4.0) 5 (10.0) 5 (10.0) 1.711 0.635 Case discussion is motivated. 44 (88.0) 5 (10.0) 1 (2.0) 0 (0.0) 42 (80.0) 2 (4.0) 6 (12.0) 0 (0.0) 4.904 0.086 The capacity of combining theory with clinical practice is built. 41 (82.0) 6 (12.0) 3 (6.0) 0 (0.0) 39 (78.0) 4 (8.0) 4 (8.0) 3 (6.0) 3.593 0.309 Team spirit and collaboration are improved. 43 (86.0) 3 (6.0) 2 (4.0) 2 (4.0) 38 (76.0) 3 (6.0) 5 (10.0) 4 (8.0) 2.261 0.520 Critical thinking is emphasised. 44 (88.0) 2 (4.0) 3 (6.0) 1 (2.0) 45 (90.0) 3 (6.0) 2 (4.0) 0 (0.0) 1.411 0.703 Teacher-trainee interactions are improved. 43 (86.0) 3 (6.0) 3 (6.0) 1 (2.0) 43 (86.0) 2 (4.0) 3 (6.0) 2 (4.0) 0.533 0.912 Practical problem-solving ability is improved. 43 (86.0) 3 (6.0) 2 (4.0) 2 (4.0) 40 (80.0) 3 (6.0) 4 (8.0) 3 (6.0) 0.975 0.807 The teaching procedure is easy to follow. 39 (78.0) 4 (8.0) 4 (8.0) 3 (6.0) 42 (84.0) 5 (10.0) 1 (2.0) 2 (4.0) 2.222 0.528 Table 3 The comparison of teaching effectiveness between TBL and CBL groups from December 2016 to April 2018 Item TBL group [cases (%)] CBL group [cases (%)] χ2 P strongly agree agree neutral disagree strongly agree agree neutral disagree Teaching objectives are clear. 224 (93.7) 11 (4.6) 4 (1.7) 0 (0.0) 195 (91.5) 12 (5.6) 4 (1.9) 2(0.1) 2.564 0.464 Key points of session topics are highlighted by tests. 214 (89.5) 19 (8.0) 5 (2.1) 1 (0.4) 185 (86.9) 13 (6.1) 10 (4.7) 5 (2.3) 6.091 0.107 Initiatives for preview are improved. 201 (84.1) 33 (13.8) 4 (1.7) 1 (0.4) 170 (79.8) 25(11.7) 14 (6.6) 4 (1.9) 9.585 0.022 Case discussion is motivated. 212 (88.7) 24 (10.0) 3 (1.3) 0 (0.0) 180 (84.5) 18 (8.5) 9 (4.2) 6 (2.8) 11.010 0.012 The capacity of combining theory with clinical practice is built. 224 (93.7) 9 (3.8) 6 (2.5) 0 (0.0) 185 (86.9) 13 (6.1) 9 (4.2) 6 (2.8) 9.573 0.021 Team spirit and collaboration are improved. 217 (90.8) 17 (7.0) 5 (2.1) 0 (0.0) 179 (84.0) 16 (7.5) 8 (3.8) 10 (4.7) 12.916 0.005 Critical thinking is emphasized. 226 (94.6) 11 (4.6) 2 (0.8) 0 (0.0) 192 (90.1) 12 (5.6) 5 (2.3) 4 (1.8) 6.621 0.085 Teacher-trainee interactions are improved. 217 (90.8) 19 (8.0) 3 (1.2) 0 (0.0) 182 (85.4) 13 (6.1) 10 (4.7) 8 (3.8) 14.517 0.002 Practical problem-solving ability is improved. 220 (92.1) 16 (6.7) 2 (0.8) 1 (0.4) 183 (85.9) 17 (8.0) 10 (4.7) 3 (1.4) 8.293 0.040 The teaching procedure is easy to follow. 214 (89.5) 21 (8.8) 4 (1.7) 0 (0.0) 192 (90.1) 12 (5.7) 9 (4.2) 0 (0.0) 4.088 0.130 Table 4 The comparison of the scores of final exams between TBL and CBL groups Enrollment period TBL CBL t P n score n score August to September in 2015 50 88.7 ± 3.5 50 87.5 ± 4.0 1.602 0.112 December 2016 to April 2018 239 88.7 ± 3.5 213 84.8 ± 4.4 2.310 0.021 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 21 Nov, 2023 Reviewers agreed at journal 20 Nov, 2023 Reviews received at journal 20 Nov, 2023 Reviewers agreed at journal 17 Nov, 2023 Reviewers invited by journal 17 Nov, 2023 Editor assigned by journal 13 Nov, 2023 Submission checks completed at journal 10 Nov, 2023 First submitted to journal 16 Sep, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3361469","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":248006025,"identity":"45243618-3006-4c9b-953b-78416b0e848a","order_by":0,"name":"Xiaohong Zhang","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaohong","middleName":"","lastName":"Zhang","suffix":""},{"id":248006026,"identity":"f73ec4e2-6dab-4e5e-9a74-57e5fd2f2dea","order_by":1,"name":"Ziying Lei","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ziying","middleName":"","lastName":"Lei","suffix":""},{"id":248006027,"identity":"128c3d04-82d7-46c0-a34d-0e34a83da266","order_by":2,"name":"Yusheng Jie","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yusheng","middleName":"","lastName":"Jie","suffix":""},{"id":248006029,"identity":"e5552f34-16cf-4c01-8a43-a230f1a1f32d","order_by":3,"name":"Yuankai Wu","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yuankai","middleName":"","lastName":"Wu","suffix":""},{"id":248006032,"identity":"a1d80a1c-bad2-4b02-9f75-8eae67d876fd","order_by":4,"name":"Yun Zhou","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yun","middleName":"","lastName":"Zhou","suffix":""},{"id":248006038,"identity":"8fa3b460-0164-47c2-a3f0-35f4290ed74f","order_by":5,"name":"ZhiXin Zhao","email":"","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"ZhiXin","middleName":"","lastName":"Zhao","suffix":""},{"id":248006039,"identity":"9c7357bd-a599-41e7-a5f9-2d9a957606fe","order_by":6,"name":"Jing Lai","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBklEQVRIiWNgGAWjYBACPgbGBoMEBgY5BgbGxgMwUQl8WtigWoyBWhqI1QIBiQ1Agkgt7IcbCh7uqE1f234YaMufw/YGB5gP3uZhsMvDqYUnscEg8czx3G1nEhsOMLYdTtxwgC3ZmochuRi3w0Ba2o7lbjsA0tJwOMHgAI+ZNA/DAbBTsWrhfwjWkm52/iHMYfzf8GuRANtSk2B2A2gLA9thxg0HeNgIaAHbcsBw2w2gLYlt6YkzD7MZW84xSMaphZ8//Znhz7Y6ebPz6Q8ffPhjbc93vPnhjTcVdji1gCwyYGA4DGEmMDQzMDCDWAa41QMB8wMGhjoYpw6PwlEwCkbBKBipAADqqV/BOoJbdQAAAABJRU5ErkJggg==","orcid":"","institution":"Third Affiliated Hospital of Sun Yat-sen University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jing","middleName":"","lastName":"Lai","suffix":""}],"badges":[],"createdAt":"2023-09-16 14:29:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3361469/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3361469/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":46386661,"identity":"4a6022d4-b75b-4772-a667-104eb7c7b4d5","added_by":"auto","created_at":"2023-11-14 03:43:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":46953,"visible":true,"origin":"","legend":"\u003cp\u003eStudy design of case discussion in clinical probation of infectious diseases\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3361469/v1/cfef895627bfc6ab711ddd1f.png"},{"id":46387929,"identity":"34f49ffd-e96d-4ef5-872e-72b0cd038680","added_by":"auto","created_at":"2023-11-14 03:51:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":353358,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3361469/v1/28fad2b0-0c99-42ce-830a-d839106b8f9c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Advanced team-based learning in clinical probation: improving initiatives for learning and team spirit of fourth year medical students","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eTeam-based learning (TBL) was first proposed by Professor Michaelsen in 2002, and expected to provide the benefits of small-group learning within large classes [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It usually includes a number of steps [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Before beginning the TBL sessions, students in the study group are divided into several teams, each consisting of 5\u0026ndash;7 individuals. These teams remain the same for all TBL sessions. The students are informed about the topic in advance. During the class, students take an individual readiness assurance test (iRAT), followed by a group readiness assurance test (gRAT). A case scenario is presented for team discussion based on the knowledge they have gained (application exercise). The session concludes with peer feedback among the teams. Since its introduction, TBL has been widely used in preclinical medical curriculum in many countries [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Previous studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] have suggested that TBL promotes self-directed learning, enhance students\u0026rsquo; adaptability in problem-solving situations, and cultivates a team spirit, rather than simply memorizing and reproducing information.\u003c/p\u003e \u003cp\u003eWe applied TBL in theoretical classes of infectious diseases at Sun Yat-sen University (SYSU) from 2012 to 2013. Within limited class time, it was difficult for teachers to conduct TBL in a large class in which there were more than 10 TBL groups. We found the teaching effectiveness of TBL was limited, similar to the findings of Whillier et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] and Burgess et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Moreover, Minges et al. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Burgess et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] supported that TBL focused on how to use theoretical knowledge. As such, TBL might be more suitable for students who have obtained basic theory, and urgently need to translate basic knowledge into clinical application.\u003c/p\u003e \u003cp\u003eClinical probation is a special stage of higher medical education in China. During this period, under the supervision of an attending physician, medical students begin to learn how to apply theoretical knowledge in clinical practice. It is also a particularly \u0026lsquo;critical phase\u0026rsquo; that affects the professional development, retention, and career success of young health professionals. Case-based learning (CBL) is the most commonly used teaching model, in which medical students work in small collaborative groups to discuss problems that are presented in a case scenario [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Compared to TBL, CBL takes less time because the teacher can guide students to the key points of case and clinical problem-solving [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Burgess et al. [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] also suggested that CBL was more relevant as students move towards clinic training.\u003c/p\u003e \u003cp\u003eHowever, many studies [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] have reported that students felt TBL was centered on teaching, but ignored student learning initiatives, which resulted in passive learning and the lack of hands-on practical training. Carrasco et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported that prior experience of TBL could improve TBL iRAT scores. Aboregela et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] believed that TBL is more beneficial to students with respect to practical sciences, because group peer teaching enhances the sense of competition.\u003c/p\u003e \u003cp\u003eA pressing challenge in the modern medical education system is how to bridge the gap between a basic theoretical curriculum and clinical practice. Burgess et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and Singh et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] highlighted an active and engaging learning strategy, and advised using randomized controlled trials to assess the effectiveness of various learning strategies. The aims of this study are to investigate the TBL teaching model in clinical probation, and evaluate its teaching effectiveness of case discussion, compared with CBL.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eThe study was hosted by the Department of Infectious Diseases, Third Affiliated Hospital of SYSU, whose design is demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. From February to July in 2015, teachers learned TBL theory and mastered its teaching skills [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn SYSU, the clinical probation syllabus of infectious diseases for undergraduate medical education includes the topics of the differential diagnosis and treatment of jaundice of unknown origin, viral hepatitis, infectious fever with multiple organ dysfunction, central nervous system infection, and parasitic diseases. Cases related to the above topics were selected, and tests were designed. Teachers also designed teaching effectiveness evaluation forms, and each item had 4 possible answers: strongly agree, agree, neutral, and disagree.\u003c/p\u003e \u003cp\u003eThe participating medical students were fourth year students at SYSU, had completed the preclinical curriculum of infectious diseases, and were ready to participate in clinical probation. The students were randomly distributed into the TBL and CBL groups. And in each group, they were divided into multiple small teams of 5\u0026ndash;7 individuals. These teams remained the same for all sessions. Two days before the case discussion, students were informed of the topic of the case discussion, and instructed to review relative theoretical knowledge by themselves. Teachers selected 3 cases for each topic. On the first day of the TBL session, students spent 25\u0026ndash;30 minutes inquiring about the medical history, and performing a physical examination on case 1. The teacher spent about 10 minutes reviewing the medical data of case 2. On the second day, students spent 20\u0026ndash;25 minutes inquiring about the medical history of case 3, and performing a physical examination.\u003c/p\u003e \u003cp\u003eSubsequently, students answered iRAT (answer 5 questions in 15 minutes), followed by gRAT (discuss 10 questions in 35 minutes) related to the 3 cases. The iRAT and gRAT contained 3 and 6 questions, respectively, to evaluate the ability of students to apply theoretical knowledge in clinical practice. Finally, students could express what they gained during the final application exercise (15 minutes). Throughout the TBL session, the teacher controlled the discussion time, and instructed students to strengthen their clinical thinking on the selected topic.\u003c/p\u003e \u003cp\u003eThere were the same number of students in the CBL group as in the TBL group. Students were also given 25\u0026ndash;30 minutes to inquire about the medical history and perform physical examinations on the cases. The teacher then spent 60 minutes directing the students to discuss the problems of the cases.\u003c/p\u003e \u003cp\u003eEach student anonymously completed teaching effectiveness evaluation forms after the case discussion. We collected and analyzed the TBL and CBL course activity and performance data, as well as the final exams score of each student.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Project modification\u003c/h2\u003e \u003cp\u003eFrom September to November in 2016, we analyzed teaching effectiveness evaluation forms and final examination scores of the TBL and CBL groups conducted in 2015, and re-studied TBL theory [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In addition, we summarized our teaching experiences from 2015 and strengthened expression, questioning, and organization of the TBL and CBL sessions. Teaching topics were chosen that strengthened the differential diagnosis and treatment of infectious fever in multiple organs. We re-selected and added related cases to clinical probation. Tests were also re-designed, with 4 and 8 questions related to clinical practice in the iRAT and gRAT, respectively. In addition, time allocation of the TBL sessions was optimized. On the second day, students spent 15 minutes inquiring about the medical history and performing a physical examination on case 3. Then students answered iRAT (10 minutes) followed by gRAT (35 minutes) questions. Finally, students could express what they gained at the final application exercise (30 minutes). To validate the results of teaching effectiveness, we enrolled more students in the study performed from December 2016 to April 2018 than in the prior study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistical analysis, the chi-square test and t-test were used to analyze the data. Statistical analyses were performed using IBM\u0026reg; SPSS\u0026reg; version 22.0 software (Armonk, NY, USA). In all analyses, a value of \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eCourse activity and performance of the students in 42 TBL teams and 40 CBL teams (5-7 students/team) were measured. Student theoretical examination scores before clinical probation of infectious diseases are shown in Table 1. There was no significant difference between the 2 groups (both, \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05).\u0026nbsp;Eligible teaching\u0026nbsp;effectiveness\u0026nbsp;evaluation forms and\u0026nbsp;final examination scores were collected from all\u0026nbsp;students.\u003c/p\u003e\n\u003cp\u003e3.1 Comparison between TBL and CBL in 2015\u003c/p\u003e\n\u003cp\u003eFrom August to September 2015, 100 students were enrolled in the study. They were randomly distributed into the TBL and CBL groups, with 50 students in each group. The results of teaching effectiveness evaluation forms are shown in Table 2, and student final examination scores are shown in Table 4. There were no significant differences between the 2 groups (all \u003cem\u003eP\u003c/em\u003e\u0026gt;0.05). However, a higher percentage of students in the TBL group indicated that the teaching model contributed to the\u0026nbsp;initiative for preview, and\u0026nbsp;motivated case discussion, team spirit, and collaboration.\u003c/p\u003e\n\u003cp\u003e3.2. Comparison between TBL and CBL from December 2016 to April 2018\u003c/p\u003e\n\u003cp\u003eA total of\u0026nbsp;239\u0026nbsp;students\u0026nbsp;participated\u0026nbsp;in TBL and 213 students were in CBL. As shown in Table 3, ratings of the TBL and CBL were similar with respect to the following items (all \u003cem\u003eP\u003c/em\u003e\u0026gt; 0.05):\u0026nbsp;(i)\u0026nbsp;teaching objectives are clear;\u0026nbsp;(ii)\u0026nbsp;key points of session topics are highlighted by tests;\u0026nbsp;(iii)\u0026nbsp;critical thinking is emphasized; (iv) the teaching procedure is easy to follow. However,\u0026nbsp;the TBL group scored the other 6 items were significantly higher than that of\u0026nbsp;CBL\u0026nbsp;group\u0026nbsp;(all \u003cem\u003eP\u003c/em\u003e\u0026lt; 0.05).\u0026nbsp;Furthermore,\u0026nbsp;the\u0026nbsp;scores of the TBL group\u0026nbsp;were also significantly\u0026nbsp;higher than those of the CBL group\u0026nbsp;(\u003cem\u003et\u003c/em\u003e= 2.310, \u003cem\u003eP\u003c/em\u003e= 0.021) in final exams. However, the mean difference was small (85.8 vs. 84.8) (Table 4).\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIt is well known that the success of medical education depends on how to combine theoretical education with clinical training [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. We optimized the TBL model in case discussions during the clinical probation of infectious diseases from 2015 to 2018 and compared with CBL. Between the TBL and CBL groups, no significant difference in students\u0026rsquo; score of theoretical exams before clinical probation (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, fourth-year medical students indicated that both the TBL and CBL teaching procedures were easy to follow. The 2 teaching models had clear teaching objectives, and emphasized critical thinking. The key points of session topics were highlighted by tests. Furthermore, our results supported that TBL more effectively improved students\u0026rsquo; initiatives for preview, and motivated case discussion, team spirit, and collaboration. Significant differences were observed between TBL and the CBL group (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e3\u003c/span\u003e) (all, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05). The results also showed that the success of TBL substantially relied on preparation based on instructor-assigned materials before the TBL session, which is consistent with the findings of Burgess et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Being informed about the topics days before discussion, students had sufficient time to preview related theories. Because iRAT and gRAT require students to apply the knowledge acquired in preparation, problems, and clinical scenarios, TBL further promoted active learning before the session. Selected cases and iRAT/gRAT questions were closely related to the teaching topic, which helped to train differential diagnosis thinking and provided more engagement during class and more responsibility for their own learning. Lochner et al. [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and Chen et al. [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e] also thought that performing individual and group assurance tests with immediate feedback in TBL encourages students to prepare themselves before class, and contributes to case discussion. Student performance and perception were improved by the implementation of TBL. Moreover, teams remained the same for all TBL sessions, and gRAT indicated improved team spirit and collaboration.\u003c/p\u003e \u003cp\u003eOn the other hand, in 2015 there were no significant differences in final examination scores between the 2 teaching models (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This may be because there were only 100 fourth-year medical students enrolled, with 50 students in each group. As TBL was used for the first time for case discussion in clinical probation of infectious diseases, we believe the experience of teachers was insufficient in the initial stage of the study. Rezende et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] reported that students did not attain better scores after TBL as compared to traditional lectures. However, Yan et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported TBL enhanced examination scores.\u003c/p\u003e \u003cp\u003eBased on the aforementioned information, we did not think the stud of 2015 provided a sufficient trial of TBL. Therefore, in the study from December 2016 to April 2018, there were 239 students in the optimized TBL model group, and 213 students in the CBL group. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the final examination scores of students in the optimized TBL model group were significantly higher than those of the students in the CBL group (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;2.310, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). This finding is consistent with that reported by Carrasco et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The assessment incentives and methods used in TBL results in student performance that better predicts performance on summative examinations. Meanwhile, we also noticed that the mean difference was small between the 2 groups (85.8 vs. 84.8) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e). This further confirmed that continuing these efforts positively impacted student assessment of TBL as a process, and increase student appreciation for TBL. Being better prepared for class, more engaged during class, and more responsible for their own learning were encouraged. Students had a more positive perception of team and teamwork, which is consistent with the results of Burgess et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Kibble et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Carrasco et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] also pointed out the importance of using different TBL grades and incentive structures so as to foster the development of well-rounded physicians. Students need long-term learning to improve their practical problem-solving ability.\u003c/p\u003e \u003cp\u003eOur study extended beyond traditional teaching methods which center on teaching, but ignores students' learning initiatives. Although this was a single center and single discipline study, it is the first time TBL was used for case discussion in clinical probation of infectious diseases. Given this success in our department, we encourage that TBL is used more in the clinical training of different medical disciplines. More students, more accurate quantitative scores, and longer-term observation will be necessary to further evaluate TBL in the future.\u003c/p\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eThe results of this 3-year study support that TBL is more effective at improving students\u0026rsquo; initiatives for preview, and motivated case discussion, team spirit, and collaboration. Continuing these efforts positively impacts student assessment of TBL as a process and increases student appreciation of it.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTBL: team-based learning; iRAT: individual readiness assurance test; gRAT: group readiness assurance test; CBL: case-based learning; SYSU: Yat-sen University\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eA\u003c/strong\u003e\u003cstrong\u003ecknowledgments\u003c/strong\u003e We would like to thank all the participating medical students for their kind participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u0026nbsp;\u003c/strong\u003eAll authors participated in the study concept and design, data acquisition, analysis, and interpretation, critical revision of the manuscript for important content, and statistical analyses. XHZ and\u0026nbsp;JL wrote the manuscript.\u0026nbsp;XHZ, ZYL, and\u0026nbsp;JL conducted the literature review and revised the manuscript. All authors read the final manuscript, and\u0026nbsp;consent to this submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ef\u003c/strong\u003e\u003cstrong\u003eunding\u0026nbsp;\u003c/strong\u003eThis study\u0026nbsp;was\u0026nbsp;supported\u0026nbsp;by\u0026nbsp;Higher\u0026nbsp;Education Teaching Reform and Teaching Quality Project\u0026nbsp;Fund\u0026nbsp;of\u0026nbsp;SYSU, numbers\u0026nbsp;No 82000-16300010 in 2011\u0026nbsp;and\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e82000-31911107 in 2016.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u0026nbsp;\u003c/strong\u003eThe data are available from the Department of Infectious Diseases, Third Affiliated Hospital of SYSU, and the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003eThe authors declare no financial or non-financial interests related to this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003eThe local Institutional Review Board of Sun Yat-sen University waived ethics approval for this research because the study protocol was not deemed to represent biomedical or epidemiological research, and no personal data were used. The procedures complied with data-protection rules, and all data were anonymized prior to analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMichaelsen LK. Team-based learning for health professions education：a guide to using small groups for improving learning. Herndon: Stylus Publishing. 2008: p.9-31.\u003c/li\u003e\n\u003cli\u003eParmelee D, Michaelsen LK, Cook S, Hudes PD. Team-based learning: a practical guide: AMEE guide no. 65. Med Teach. 2013;34(5):e275-87. https://doi.10.3109/0142159X.2012.651179.\u003c/li\u003e\n\u003cli\u003eShetty SR, Babu GS, Castelino R, Hegde S, Rao PK, Kishor S. Case‑based, Team‑based Learning: A Novel Method for Teaching Orofacial Syndromology to Dental Undergraduate Students. Educ Health (Abingdon). 2015;28(1):112-3. https://doi.10.4103/1357-6283.161957.\u003c/li\u003e\n\u003cli\u003eConsidine J, Berry D, Allen J, Hewitt N, Oldland E, Sprogis SK, Currey J. Team-based learning in nursing education: A scoping review. J Clin Nurs. 2021;30(7-8):903-17. https://doi.10.1111/jocn.15599.\u003c/li\u003e\n\u003cli\u003ePark SE, Salihoglu-Yener E, Fazio SB. Use of team-based learning pedagogy for predoctoral teaching and learning. Eur J Dent Educ. 2018;23(1):e32-6. https://doi.10.1111/eje.12396.\u003c/li\u003e\n\u003cli\u003eWhillier S, Lystad RP, El-Haddad J. Team-based learning in neuroanatomy. J Chiropr Educ. 2021;35(2):184-91. https://doi.10.7899/JCE-19-25.\u003c/li\u003e\n\u003cli\u003eBurgess A, van Diggele C, Roberts C, Mellis C. Team-based learning: design, facilitation and participation. BMC Med Educ. 2020;20(Suppl2):461. https://doi.10.1186/s12909-020-02287-y.\u003c/li\u003e\n\u003cli\u003eMinges KE. Team-Based Learningin the Clinical Setting: Perspectives of Doctor of Nursing Practice Students. J Dr Nurs Pract. 2019;12(1):41-5. https://doi.10.1891/2380-9418.12.1.41.\u003c/li\u003e\n\u003cli\u003eBurgess A, Haq I, Bleasel J, Roberts C, Garsia R, Randal N, et al. Team-based learning (TBL): a community of practice. BMC Med Educ. 2019;19(1):369. https://doi.10.1186/s12909-019-1795-4.\u003c/li\u003e\n\u003cli\u003eBurgess, A, Matar, E. Team-Based Learning (TBL): Theory, Planning, Practice, and Implementation. In: Nestel, D., Reedy, G., McKenna, L., Gough, S. (eds) Clinical Education for the Health Professions. Springer, Singapore 2020. https://doi.org/10.1007/978-981-13-6106-7_128-1.\u003c/li\u003e\n\u003cli\u003eBurgess A, Matar E, Roberts C, Haq I, Wynter L, Singer J, et al. Scaffolding medical student knowledge and skills: team-based learning (TBL) and case-based learning (CBL). BMC Med Educ. 2021;21(1):238. https://doi.org/10.1186/s12909-021-02638-3.\u003c/li\u003e\n\u003cli\u003eNational Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Global Health; Global Forum on Innovation in Health Professional Education. Improving Health Professional Education and Practice Through Technology: Proceedings of a Workshop. Washington (DC): National Academies Press (US); 2018 Apr 25. https://doi.10.17226/25072.\u003c/li\u003e\n\u003cli\u003eCarrasco GA, Gentile M, Salvatore ML, Lopez OJ, Behling KC. Implementation of team-based learning (TBL) in a second-year medical school course: does prior experience with TBL improve the impact of this pedagogy? BMC Med Educ. 2022;22(1):288. https://doi.10.1186/s12909-022-03363-1.\u003c/li\u003e\n\u003cli\u003eAdel M. Aboregela, Hany M.A. Sonpol, Ashraf S. Metwally, Ayman M. El-Ashkar, Abdullah A. Hashish, Osama A. Mohammed, et al. Medical students\u0026rsquo; perception and academic performance after team-based and seminar-based learning in human anatomy. Journal of Taibah University Medical Sciences. 2023;18(1): 65-73. https://doi.org/10.1016/j.jtumed.2022.08.005\u003c/li\u003e\n\u003cli\u003eSingh K, Bharatha A, Sa B, Adams OP, Majumder MAA. Teaching anatomy using an active and engaging learning strategy. BMC Med Educ. 2019;19(1):149. https://doi.org/10.1186/s12909-019-1590-2.\u003c/li\u003e\n\u003cli\u003eLochner L, Wieser H, Oberho\u0026uml;ller G, Ausserhofer D. Interprofessional team-based learning in basic sciences: students\u0026rsquo; attitude and perception of communication and teamwork. Int J Med Educ 2020;11:214-21. https://doi.10.5116/ijme.5f5b.24e3.\u003c/li\u003e\n\u003cli\u003eChen M, Ni C, Hu Y, Wang M, Liu L, Ji X, et al. Meta-analysis on the effectiveness of team-based learning on medical education in China. BMC Med Educ. 2018;18:77. https://doi.10.1186/s12909-018-1179-1.\u003c/li\u003e\n\u003cli\u003eRezende AB, de Oliveira AG, Vale TC, Teixeira LA, Lima AR, Lucchetti AL, et al. Comparison of team-based learning versus traditional lectures in neuroanatomy: medical student knowledge and satisfaction. Anat Sci Educ. 2020;13:591-601. https://doi.10.1002/ase.1926.\u003c/li\u003e\n\u003cli\u003eYan J, Ding X, Xiong L, Liu E, Zhang Y, Luan Y, et al. Team based learning: assessing the impact on anatomy teaching in People\u0026rsquo;s Republic of China. Adv Med Educ Pract. 2018;9: 589-94. https://doi.10.2147/AMEP.S169949. eCollection 2018.\u003c/li\u003e\n\u003cli\u003eKibble JD, Bellew C, Asmar A, Barkley L. Team-based learning in large enrollment classes. Adv Physiol Educ. 2016, 40(4):435-42. https://doi.10.1152/advan.00095.2016.\u003c/li\u003e\n\u003cli\u003eCarrasco GA, Behling KC, Lopez OJ. Implementation of Team-Based Learning: a Tale of Two New Medical Schools. Med Sci Educ. 2019;29(4):1201-10. https://doi.10.1007/s40670-019-00815-0.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1\u0026nbsp;\u003c/strong\u003eThe comparison of\u0026nbsp;the scores of theoretical exams before clinical probation between\u0026nbsp;TBL and CBL groups\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.513513513513516%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnrollment period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.9009009009009%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBL group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.8828828828828827%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.36036036036036%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBL group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17117117117117%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17117117117117%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.70731707317073%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003escore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.504065040650406%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.447154471544716%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.89430894308943%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003escore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.45323741007194%\" valign=\"top\"\u003e\n \u003cp\u003eAugust to September in 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.83453237410072%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.028776978417266%\" valign=\"top\"\u003e\n \u003cp\u003e77.1\u0026nbsp;\u0026plusmn; 5.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.8776978417266186%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.83453237410072%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.66906474820144%\" valign=\"top\"\u003e\n \u003cp\u003e77.3\u0026nbsp;\u0026plusmn; 6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.151079136690647%\" valign=\"top\"\u003e\n \u003cp\u003e-0.183\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.151079136690647%\" valign=\"top\"\u003e\n \u003cp\u003e0.855\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"33.45323741007194%\" valign=\"top\"\u003e\n \u003cp\u003eDecember 2016 to April 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.83453237410072%\" valign=\"top\"\u003e\n \u003cp\u003e239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.028776978417266%\" valign=\"top\"\u003e\n \u003cp\u003e77.0\u0026nbsp;\u0026plusmn; 8.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.8776978417266186%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.83453237410072%\" valign=\"top\"\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.66906474820144%\" valign=\"top\"\u003e\n \u003cp\u003e76.9\u0026nbsp;\u0026plusmn; 8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.151079136690647%\" valign=\"top\"\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.151079136690647%\" valign=\"top\"\u003e\n \u003cp\u003e0.490\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003ea\u0026nbsp;\u003c/sup\u003eTBL: Team-Based Learning; CBL: Case-based learning.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u0026nbsp;\u003c/strong\u003eThe comparison of teaching effectiveness between TBL and CBL groups in 2015\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"928\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" rowspan=\"2\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.386437029063508%\" colspan=\"4\" valign=\"top\" style=\"width: 31.7308%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBL group [cases (%)]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.92465016146394%\" colspan=\"4\" valign=\"top\" style=\"width: 23.7762%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBL group [cases (%)]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" rowspan=\"2\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" rowspan=\"2\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e\u003cstrong\u003estrongly agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.929824561403509%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.228070175438596%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eneutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e\u003cstrong\u003edisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.982456140350877%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e\u003cstrong\u003estrongly agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.982456140350877%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eneutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e\u003cstrong\u003edisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eTeaching objectives are clear.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e45 (90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e44 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.211\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.900\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eKey points of session topics are highlighted by tests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e44 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e43 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.745\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.863\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eInitiatives for preview are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e41 (82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e38 (76.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e5 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e5 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e1.711\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.635\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eCase discussion is motivated.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e44 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e5 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e42 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e6 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e4.904\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eThe capacity of combining theory with clinical practice is built.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e41 (82.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e6 (12.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e39 (78.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e3.593\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.309\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 17.1329%;\"\u003e\n \u003cp\u003eTeam spirit and collaboration are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.8287%;\"\u003e\n \u003cp\u003e43 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.6049%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.5175%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.7797%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.6538%;\"\u003e\n \u003cp\u003e38 (76.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.6818%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 4.458%;\"\u003e\n \u003cp\u003e5 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 5.0699%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e2.261\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 3.2343%;\"\u003e\n \u003cp\u003e0.520\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"928\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 27.7228%;\"\u003e\n \u003cp\u003eCritical thinking is emphasised.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.3608%;\"\u003e\n \u003cp\u003e44 (88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.4807%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.0407%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e45 (90.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 5.3905%;\"\u003e\n \u003cp\u003e1.411\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 6.2706%;\"\u003e\n \u003cp\u003e0.703\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 27.7228%;\"\u003e\n \u003cp\u003eTeacher-trainee interactions are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.3608%;\"\u003e\n \u003cp\u003e43 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.4807%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.0407%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e43 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 5.3905%;\"\u003e\n \u003cp\u003e0.533\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 6.2706%;\"\u003e\n \u003cp\u003e0.912\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 27.7228%;\"\u003e\n \u003cp\u003ePractical problem-solving ability is improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.3608%;\"\u003e\n \u003cp\u003e43 (86.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.4807%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.0407%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e40 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 5.3905%;\"\u003e\n \u003cp\u003e0.975\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 6.2706%;\"\u003e\n \u003cp\u003e0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.233584499461788%\" valign=\"top\" style=\"width: 27.7228%;\"\u003e\n \u003cp\u003eThe teaching procedure is easy to follow.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.180839612486544%\" valign=\"top\" style=\"width: 8.3608%;\"\u003e\n \u003cp\u003e39 (78.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.3196986006458555%\" valign=\"top\" style=\"width: 7.4807%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.889128094725511%\" valign=\"top\" style=\"width: 7.0407%;\"\u003e\n \u003cp\u003e4 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e3 (6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e42 (84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e5 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.965554359526372%\" valign=\"top\" style=\"width: 8.1408%;\"\u003e\n \u003cp\u003e1 (2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.996770721205597%\" valign=\"top\" style=\"width: 7.1507%;\"\u003e\n \u003cp\u003e2 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.27448869752422%\" valign=\"top\" style=\"width: 5.3905%;\"\u003e\n \u003cp\u003e2.222\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.135629709364909%\" valign=\"top\" style=\"width: 6.2706%;\"\u003e\n \u003cp\u003e0.528\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eThe comparison of teaching effectiveness between TBL and CBL groups from December 2016 to April 2018\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"934\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.116827438370848%\" rowspan=\"2\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"29.260450160771704%\" colspan=\"4\" valign=\"top\" style=\"width: 31.0856%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBL group [cases (%)]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.010718113612004%\" colspan=\"4\" valign=\"top\" style=\"width: 24.3316%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBL group [cases (%)]\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.787781350482315%\" rowspan=\"2\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026chi;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.109324758842444%\" rowspan=\"2\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.333333333333334%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e\u003cstrong\u003estrongly agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.929824561403509%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.228070175438596%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eneutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e\u003cstrong\u003edisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"13.508771929824562%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e\u003cstrong\u003estrongly agree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.982456140350877%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eneutral\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.403508771929825%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e\u003cstrong\u003edisagree\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eTeaching objectives are clear.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e224 (93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e11 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e195 (91.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e12 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e4 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e2(0.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e2.564\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eKey points of session topics are highlighted by tests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e214 (89.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e19 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e5 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e185 (86.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e13 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e10 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e5 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e6.091\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.107\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eInitiatives for preview are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e201 (84.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e33 (13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e170 (79.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e25(11.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e14 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e4 (1.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e9.585\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.022\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eCase discussion is motivated.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e212 (88.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e24 (10.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e3 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e180 (84.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e18 (8.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e9 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e6 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e11.010\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.012\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eThe capacity of combining theory with clinical practice is built.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e224 (93.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e9 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e6 (2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e185 (86.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e13 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e9 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e6 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e9.573\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 16.6252%;\"\u003e\n \u003cp\u003eTeam spirit and collaboration are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.6589%;\"\u003e\n \u003cp\u003e217 (90.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e17 (7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 7.3601%;\"\u003e\n \u003cp\u003e5 (2.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.7065%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.7455%;\"\u003e\n \u003cp\u003e179 (84.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 6.2344%;\"\u003e\n \u003cp\u003e16 (7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 4.4161%;\"\u003e\n \u003cp\u003e8 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 5.0222%;\"\u003e\n \u003cp\u003e10 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 3.8965%;\"\u003e\n \u003cp\u003e12.916\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 3.2038%;\"\u003e\n \u003cp\u003e0.005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"934\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 27.5599%;\"\u003e\n \u003cp\u003eCritical thinking is emphasized.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.2789%;\"\u003e\n \u003cp\u003e226 (94.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.4074%;\"\u003e\n \u003cp\u003e11 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 6.9717%;\"\u003e\n \u003cp\u003e2 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.3878%;\"\u003e\n \u003cp\u003e192 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e12 (5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 8.061%;\"\u003e\n \u003cp\u003e5 (2.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e4 (1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 5.8824%;\"\u003e\n \u003cp\u003e6.621\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 6.2092%;\"\u003e\n \u003cp\u003e0.085\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 27.5599%;\"\u003e\n \u003cp\u003eTeacher-trainee interactions are improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.2789%;\"\u003e\n \u003cp\u003e217 (90.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.4074%;\"\u003e\n \u003cp\u003e19 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 6.9717%;\"\u003e\n \u003cp\u003e3 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.3878%;\"\u003e\n \u003cp\u003e182 (85.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e13 (6.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 8.061%;\"\u003e\n \u003cp\u003e10 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e8 (3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 5.8824%;\"\u003e\n \u003cp\u003e14.517\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 6.2092%;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 27.5599%;\"\u003e\n \u003cp\u003ePractical problem-solving ability is improved.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.2789%;\"\u003e\n \u003cp\u003e220 (92.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.4074%;\"\u003e\n \u003cp\u003e16 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 6.9717%;\"\u003e\n \u003cp\u003e2 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e1 (0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.3878%;\"\u003e\n \u003cp\u003e183 (85.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e17 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 8.061%;\"\u003e\n \u003cp\u003e10 (4.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e3 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 5.8824%;\"\u003e\n \u003cp\u003e8.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 6.2092%;\"\u003e\n \u003cp\u003e0.040\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"27.08779443254818%\" valign=\"top\" style=\"width: 27.5599%;\"\u003e\n \u003cp\u003eThe teaching procedure is easy to follow.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.137044967880085%\" valign=\"top\" style=\"width: 8.2789%;\"\u003e\n \u003cp\u003e214 (89.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.28051391862955%\" valign=\"top\" style=\"width: 7.4074%;\"\u003e\n \u003cp\u003e21 (8.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.852248394004283%\" valign=\"top\" style=\"width: 6.9717%;\"\u003e\n \u003cp\u003e4 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.244111349036402%\" valign=\"top\" style=\"width: 8.3878%;\"\u003e\n \u003cp\u003e192 (90.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e12 (5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.922912205567452%\" valign=\"top\" style=\"width: 8.061%;\"\u003e\n \u003cp\u003e9 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.9593147751606%\" valign=\"top\" style=\"width: 7.0806%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"5.781584582441114%\" valign=\"top\" style=\"width: 5.8824%;\"\u003e\n \u003cp\u003e4.088\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.102783725910064%\" valign=\"top\" style=\"width: 6.2092%;\"\u003e\n \u003cp\u003e0.130\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003eThe comparison of\u0026nbsp;the scores of final exams between\u0026nbsp;TBL and CBL groups\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.48275862068966%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEnrollment period\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.234119782214155%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTBL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.9038112522686026%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.77858439201452%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCBL\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003et\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003eP\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"15.019762845849803%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"31.225296442687746%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003escore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.324110671936759%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.019762845849803%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.41106719367589%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003escore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eAugust to September in 2015\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.896551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.337568058076226%\" valign=\"top\"\u003e\n \u003cp\u003e88.7\u0026nbsp;\u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.9038112522686026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.896551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.882032667876588%\" valign=\"top\"\u003e\n \u003cp\u003e87.5\u0026nbsp;\u0026plusmn; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" valign=\"top\"\u003e\n \u003cp\u003e1.602\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" valign=\"top\"\u003e\n \u003cp\u003e0.112\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.48275862068966%\" valign=\"top\"\u003e\n \u003cp\u003eDecember 2016 to April 2018\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.896551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e239\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.337568058076226%\" valign=\"top\"\u003e\n \u003cp\u003e88.7\u0026nbsp;\u0026plusmn; 3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"2.9038112522686026%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.896551724137931%\" valign=\"top\"\u003e\n \u003cp\u003e213\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.882032667876588%\" valign=\"top\"\u003e\n \u003cp\u003e84.8\u0026nbsp;\u0026plusmn; 4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" valign=\"top\"\u003e\n \u003cp\u003e2.310\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.800362976406534%\" valign=\"top\"\u003e\n \u003cp\u003e0.021\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"discover-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diedu","sideBox":"Learn more about [Discover Education](https://www.springer.com/journal/44217)","snPcode":"44217","submissionUrl":"https://submission.nature.com/new-submission/44217/3","title":"Discover Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Team-based learning (TBL), teaching effectiveness, clinical probation, case-based learning (CBL)","lastPublishedDoi":"10.21203/rs.3.rs-3361469/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3361469/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eTeam-based learning (TBL) is widely used in preclinical medical curriculum. The aims of this study were to investigate the TBL teaching model in clinical probation and evaluate its teaching effectiveness in case discussion, compared with case-based learning (CBL). Fourth-year medical students who participated in clinical probation of infectious diseases were randomly distributed into the TBL and CBL groups. Each student anonymously completed teaching effectiveness evaluation forms after case discussions, and after the final examination. From August to September 2015, 100 students were enrolled. Both groups had clear teaching objectives and easy to follow teaching procedures. A higher percentage of students in the TBL group agreed that TBL contributed to the initiatives for preview and motivated case discussion, team spirit, and collaboration; but differences between the 2 groups were not significant \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e(\u003c/span\u003eall \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). From December 2016 to April 2018, 239 students participated in TBL and 213 students in CBL. Compared with the CBL group, TBL received significantly higher scores of the above items (all \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05), and also significantly higher scores with respect to the capacity of combining theory with clinical practice, and improved teacher-trainee interactions and practical problem-solving ability. The final examination scores of the TBL group were significantly higher than those of the CBL group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021). In conclusion, TBL is more effective for improving medical student initiatives for preview and motivated case discussion, team spirit, and collaboration. Continuing efforts positively impacted student assessment of TBL and increased student appreciation for it.\u003c/p\u003e","manuscriptTitle":"Advanced team-based learning in clinical probation: improving initiatives for learning and team spirit of fourth year medical students","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-11-14 03:43:20","doi":"10.21203/rs.3.rs-3361469/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"d0abda1b-acc7-46f3-81a2-c218c44148bb","date":"2023-11-21T05:13:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"98a127e2-d490-42ac-bf74-2b674a07420c","date":"2023-11-20T18:30:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-11-20T09:16:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"e585f4ef-d2d3-4098-b95e-6d3df05ec65b_SNPRID","date":"2023-11-17T19:13:21+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-11-17T18:26:54+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-11-13T05:16:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-11-10T14:05:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Discover Education","date":"2023-09-16T14:22:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"discover-education","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"diedu","sideBox":"Learn more about [Discover Education](https://www.springer.com/journal/44217)","snPcode":"44217","submissionUrl":"https://submission.nature.com/new-submission/44217/3","title":"Discover Education","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Discover Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f52d8624-f9b6-424b-a251-f1da268ccecd","owner":[],"postedDate":"November 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2023-11-14T03:43:21+00:00","versionOfRecord":[],"versionCreatedAt":"2023-11-14 03:43:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3361469","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3361469","identity":"rs-3361469","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}