Team-Based Learning (TBL) 101

Laura Willett, MD, FACP

Rutgers Robert Wood Johnson Medical School
 Pre-test
• Sit with some people you don’t know.
• Please read the pre-reading if you haven’t
already done so.
• You may take the pre-test (RAT) individually
but do not discuss until further instructed.
• The test is “open book”
 Team-Based Learning (TBL) 101
Objectives
• Describe team-based learning (TBL) stages
• Experience TBL from the learner standpoint
• Describe the steps to design a new TBL
experience
• List some of the challenges of TBL
 Agenda of Today’s Session
• Introduction
• Demonstrate basics of TBL using a TBL format
• Example of TBL sessions
• Questions/comments
– “Can I do this in my teaching?”
– “How can I convert existing sessions to TBL
format?”
 My uses of modified TBL
• M2 endocrinology case sessions instead of
“small” groups of 25-30 (n≈80)
• Resident noon conferences (n≈20)
• M2 EBM (evidence-based medicine) case
sessions (n≈170)

• Your experiences with TBL?

Barriers/challenges in teaching adults?
• Perceived weaknesses of lectures
Barriers/challenges in teaching adults
 Barriers/challenges in teaching adults

• Attendance
• Learner preparation – responsibility and
accountability for “doing their part” to master
new material
• Learner engagement in the learning process
• Retention and understanding with lectures
 What is TBL?
(a “flipped classroom” modality)
• Alternative strategy to lecture
• Learners accountable to prepare before class
• Team/group of learners
– Accountable to each other for teaching and
respect
– APPLICATION of material occurs in class

– RESULTS: ENGAGED AND ACTIVE LEARNERS

TEACHING EACH OTHER
 Phases of TBL
• Preparation (Individual study)
• Readiness Assurance Testing
– Individual (IRAT)
– Group (GRAT)
• Application of Concepts
– Small group teams during class

• Additional components:
– Appeals process
– Peer evaluation
 Applying phases of TBL
• Preparation (Individual study)
• Team formation – 5-7, distribute strength
• Readiness Assurance Testing
– Individual (IRAT)
– Group (GRAT)
• Application of Concepts
– Small group teams during class
 Applying phases of TBL
• Preparation (Individual study)
• Team formation
• Readiness Assurance Testing
– Individual (IRAT)
– Group (GRAT)
• Application of Concepts
– Small group teams during class
 Applying phases of TBL
• Preparation (Individual study)
• Team formation
• Readiness Assurance Testing
– Individual (IRAT)
– Group (GRAT)
• Application of Concepts
– Small group teams during class
 Your new course
• Putting together a new course
• Who plans, who teaches?
• Pre-readings, RATs, exercises
• Faculty complaints
• Student complaints
• Grading
 Your TBL course
• You are asked to put together a new first-year
medical school course, combining the
objectives from prior courses in anatomy,
physiology, biochemistry, microbiology,
histology (microscopy), health and society,
and clinical medicine, using TBL as the primary
instructional method.
• We will focus on a session regarding the
throat, using sore throat as a learning tool.
 Who should have input into TBL
exercises?
1. Anatomist
13% 13% 13% 13% 13% 13% 13% 13%

2. Physiologist
3. Biochemist
4. Histologist
5. Microbiologist
6. Clinician
7. Advanced student
8. All of the above
1. 2. 3. 4. 5. 6. 7. 8.
What faculty should be present for TBL
exercises?
1. Anatomist
13% 13% 13% 13% 13% 13% 13% 13%

2. Physiologist
3. Biochemist
4. Histologist
5. Microbiologist
6. Clinician
7. Advanced student
8. Any of the above
1. 2. 3. 4. 5. 6. 7. 8.
 What mechanism will you use to
determine pre-readings?
1. Ask clinicians what
25% 25% 25% 25%
information is most useful for
students to know
2. Ask clinicians what students
will be expected to do
3. Ask each course contributor
what information is most
useful for students
4. Include all assigned reading
from previous independent
courses

1. 2. 3. 4.
Readiness assessment test (RAT) questions
Open discussion
• What would be an appropriate anatomy-
based question for the sore throat RAT?

• (We covered this concept in our RAT)

 RAT questions
Open discussion
• What would be an appropriate anatomy-
based question for the sore throat RAT?

• Can be MCQ, short-answer, drawing

 What would be appropriate
application questions?
1. List the most common 25% 25% 25% 25%
causes of sore throat
2. List mechanisms of toxicity
for most common microbes
3. Evaluate questions to
patients about possible
sexual exposures causing
sore throat
4. “Walk through” a case of
sore throat, making
decisions along the way

1. 2. 3. 4.
 Faculty complaint
Discussion question
• The microbiology expert complains that your
TBL case doesn’t sufficiently emphasize the
different mechanisms of illness associated
with different microorganisms.
• She doesn’t feel that this technique allows her
to cover as many specific points as she did in
her lectures. Is she right?
 Faculty complaint
Discussion question
• She doesn’t feel that this technique allows her
to cover as many specific points as she did in
her lectures. Is she right?
• What would you say?
 Student complaint
• Five students meet with you to complain that
one of their team members is overbearing,
and imposes his/her answer for the team RAT
(GRAT) without allowing for much discussion.
This has caused them to lose points towards
their final grade.
• How would you address this problem?
 The overbearing student
• A. Assign the overbearing student to another team
• B. Circulate during the GRAT and application
exercises to encourage within-team discussion
• C. Institute formative peer evaluation halfway
through course
• D. Institute summative (affects grade) peer
evaluation at end of course
• E. Re-shuffle all teams halfway through course
• F. Rotate assignment of “scribe” to different team
members
 The overbearing student
A. Assign overbearing 17% 17% 17% 17% 17% 17%
student
B. Circulate during GRAT
C. Formative peer eval
D. Summative peer eval
E. Reshuffle everyone
F. Rotate “scribe”
Now for the students’ most important
question…
Now for the students’ most important
question…
• What affects my grade?
Now for the students’ most important
question…
• What affects my grade?
• TBL components that can contribute:
– IRAT
– GRAT
– Application exercises
– Peer evaluation
 Which of the following is MOST
problematic to contribute to final grade?
A. IRAT 25% 25% 25% 25%

B. GRAT
C. Application exercises
D. Peer evaluation
 Discussion points
• Team construction
• Pre-readings, assigned vs. objectives
• RATs
• Application exercises
• Grade implications
Some actual examples
 M2 STUDENT SAMPLE
CLINICAL APPLICATIONS EBM
 Pre-test
• Ensure that you have at least one person who
pre-read each article
• Do first by yourself for your own feedback
• Then do as team
– Write all names legibly
– Indicate answers clearly
– Will collect for grading
 “Readiness Assessment Test”
• What is the definition of sensitivity?
• Out of all the people who AAAA, this
percentage BBBB.

•X
 X Sensitivity – Out of all the people who
30
AAAA, this percentage BBBB
1. have disease – have pos
25% 25% 25% 25%
test
2. don’t have disease- have
neg test
3. have pos test – have
disease
4. have a neg test – don’t
have disease
5. get test done – have
disease

0
1 2 3 4
 Case 1
• A 25-year-old woman, uninsured, taking oral
contraceptive pills comes to the ER for acute
onset of shortness of breath 2 hours earlier.
• No other symptoms – just can’t catch her
breath. No other significant PMH or
medications.
 Case 1 - continued
• Currently comfortable
• P 88, BP 110/62, R 14, T 98.2, oxygen 98%
• Exam normal
• Chest X-ray normal

• She is concerned that she may have a pulmonary

embolism (PE), and you find out that her
grandmother recently died of pulmonary embolism
after hip surgery.
 What is her risk of PE?
30

1. Low (<10%)
33% 33% 33%
2. Medium
3. High (>50%)

0
1 2 3
 PE Clinical Diagnosis – Wells low <2,
high >6
• 1.5 Prior PE or DVT
• 1.5 Pulse >100
• 1.5 Surgery or immobilization
• 3 Signs of deep venous thrombosis
• 1 Hemoptysis (coughing up blood)
• 1 Cancer
• 3 Alternative diagnosis less likely
 Case 1 - continued
• A D-dimer blood test is sent and comes back
negative
• Sensitivity is 96% (define?)
• Specificity is 50% (define?)
• Assume a pre-test probability of 5% (define?)

• With a negative D-dimer, her chance of having PE is

closest to <1%, 2%, 4%, 10%, 70%?
• (Hint – start with 1,000 people)
 Case 1 – neg D-dimer
pre-test prob 5%, sens 96%, spec 50%
30

1. <1% 20% 20% 20% 20% 20%

2. Approx 2%
3. Approx 4%
4. Approx 10%
5. Approx 70%

0
1 2 3 4 5
RESIDENT SAMPLE - Venous
Thromboembolism
 Diagnosis - Pre-test
• Which is sensitivity?
– A. Of everyone with the disease, this proportion test
positive
– B. Of everyone without the disease, this proportion test
negative
– C. Of everyone with a positive test, this proportion have
the disease
– D. Of everyone with a negative test, this proportion do not
have the disease
 Outline
 Epidemiology/risk factors
 Diagnosis - clinical and tests
 Outcomes with treatment
 Special situations
 IVC filters
 Case 1
• A 22-year-old generally healthy woman, an
undocumented immigrant, comes to the ER 1 week
after a Ceasarean delivery, complaining of pain and
swelling of the left leg.
• The leg is grossly swollen and tender from the thigh
down, with prominent tortuous veins.
• A D-dimer is ordered by the PA.
 Case 1 – Clinical probablilty?
• A. High
• B. Intermediate
• C. Low
 DVT – Clinical Diagnosis
Wells Criteria
• 1 Active cancer
• 1 Paralysis or immobilization
• 1 Major surgery or bedridden >3d
• 1 Localized tenderness
• 1 Entire leg swollen
• 1 Calf >3cm larger than other side
• 1 Collateral superficial veins
• -2 Alternative diagnosis at least as likely
 DVT – Clinical Diagnosis
Wells criteria
• Overall prevalence higher in inpatients
• Approximate prevalence in outpatients
– Low (0 or less) 5%
– Moderate (1 or 2) 17%
– High (3 or more) 53%
 DVT – Testing
Do AFTER clinical eval
• D-dimer (?age-adjusted)
• Contrast venography
• Ultrasound compressibility
• CT or MR venogram
• Do these have (vote separately):
– A. Sensitivity high
– B. Specificity high
– C. Both high
– D. Insufficient information
 Case 1 – two questions
• What will you do if her D-dimer is positive?
What if it is negative?
– A. Admit for LMWH/warfarin
– B. Send home for LMWH/warfarin
– C. Obtain compression ultrasound
– D. Obtain venogram
– E. Send home without therapy
 Case 1 – D-dimer results

DVT + DVT -

D-dimer + 57 20 77

D-dimer - 3 20 23

60 40 100
 Case 1 – D-dimer results

DVT + DVT -

D-dimer + 57 20 77
57/77 = 74%
D-dimer - 3 20 23
3/23 = 13%
60 40 100
 Discussion points
• Team construction
– For single session vs. multiple sessions
• Pre-readings, assigned vs. objectives
• RATs
• Application exercises
• Grade implications