The history and future of Team-Based Learning

Something about the beginning of a new year compels us to peer into the crystal ball of prophecies and to wax prophetic about the changes we foresee coming. This year is no different, and, in fact, the New Year represents an opportune time for us to reflect on our fundamental educational approach, Team Based Learning, as well as to envision the future of medical education. However, before we begin to conjure our inner Nostradamuses, it is important for us to understand our past and how we have arrived in the present. To do so, we provide here an abbreviated historical perspective.

Classic antiquity period (prior to 1910)

Prior to the first standard ever written by the American Medical Association’s Council on Medical Education in 1904, which declared that medical education must consist of two years of study of anatomy and physiology followed by two years of clinical training, there was wide variability in terms of what passed as medical education. Many programs were run as for-profit endeavors and lacked adequate oversight or accountability systems. Abraham Flexner, in his 1910 report, highlighted this variability and documented the systematic conditions that led to highly ineffective teaching among many medical education programs. ¹

Medieval period (1910s to 1960s)

Driven by the impact of the Flexner Report, medical education became a professional endeavor characterized by being taught by competent medical school faculty and emphasizing the scientific method as the basis for medical knowledge. However, this period of medical education was still largely characterized by passive educational strategies. Medical educators highly valued the role of lecturing and demonstration as the primary sources of information dissemination, as developed by the great orators of the Greek antiquity. Medical school administrators were quick to accept this approach due to the economical and logistical ease it required. Educational research regarding teaching and learning had yet to play a significant role in the practice of teaching.

Early modern period (late 1960s to early 2000s)

This changed, however, in the late 1960s when McMaster University in Toronto, Canada, began the first ‘Problem-Based Learning’ (PBL) curriculum. In this active educational approach, learners engaged in the solving of open-ended problems, with an emphasis on identifying the key information that was unknown in order to solve the problem. Typically conducted in small groups led by faculty facilitators, PBL represented a significant improvement in the pedagogical practices of medical education. ² Unfortunately, evidence from PBL curriculums oftentimes did not yield noticeable improvements in outcomes. ³ Perhaps one reason why this may have been the case is the high variability among the faculty facilitators’ actions when in their small groups. In short, the PBL approach, while a fundamentally strong and potentially powerful educational strategy, was limited in practice by the heavy manpower needs and the extensive faculty development that it required to provide a standardized educational experience for all students.

Modern era (2000s to present)

As valuable as PBL is as an active learning strategy, medical schools found that it had some limitations, such as ensuring that there were adequately trained faculty members to ensure consistency of experiences between small groups, and providing for the physical space necessary for small groups to work independently. Given these challenges, alternative educational modalities were sought that would not have the same logistical challenges. While medical schools were struggling with these challenges, business school faculty members were experimenting with their own active learning strategies, one of which was termed ‘Team-Based Learning’ (TBL). ⁴

In TBL activities, individual students are initially provided with faculty directed content (e.g. lectures, readings, etc.) on basic concepts and principles. This may be done via traditional in-school lectures or via ‘flipped classroom’ methods where the responsibility of initially learning the content is placed outside of the classroom. In TBL activities, students are then assessed on their individual mastery of the content via a test. Following the individual testing, students retake the exact same test (closed book) in pre-assigned teams, and submit a single best answer for their team. This time, the team immediately finds out if their team consensus submission was correct or not. Following this session, the teams are given a clinically oriented problem (often similar to a PBL problem) and apply the knowledge gained so far in order to answer questions related to the case. The case may be directly related to the pre-class content, or may build on any content from within the course. One of the advantages of TBL, for faculty, is that it is a well-defined, structured process that, if followed, will give good academic results and can serve to minimize the variability of the content expert’s innate or learned educational skills, or lack thereof. Duke-NUS was one of the first medical schools in the world to recognize the value of this approach in medical education and fully implement it as a primary pedagogical approach for the basic science instruction.

As a whole, the body of available evidence suggests that TBL is an effective method of instruction that results in improved learning outcomes for students, especially for the bottom 20%. While this is certainly a desirable (and necessary) outcome in favor of continuing to use TBL, there is a belief that TBL promotes and enables students to practice other important skills and competencies of the 21st century professional such as communication, leadership and teamwork skills; however, more research is needed to determine how or if this is transferable to other learning environments.

The future

There is a growing interest in ensuring that medical educational programs develop students’ competencies for ‘self-directed learning’. This important concept requires that students take the initiative and responsibility for their own learning, including selecting and assessing their learning goals at their own time and place. There are critics of TBL that suggest the highly prescribed content delivery and activities associated with the TBL process do not support this competency. While we are not sure that we agree with this assertion, we are content with the implications because we do not believe that TBL is the only approach toward education. In fact, we believe it is merely one tool in the toolbox, and that we must be well versed with many educational approaches given the goals of education. Creating strategies to achieve the broader needs of our learners is an exciting challenge, and we should not be afraid of tweaking the TBL process or abandoning it altogether in order to solve such challenges. In an early nod to this notion, we at Duke-NUS made the early decision to refer to our overall teaching strategy as ‘TeamLEAD’ (Learn, Engage, Apply, Develop) rather than TBL. This symbolic gesture enables Duke-NUS to look forward to the future in order to enhance and supplement the typical TBL model to address the broader professional skills necessary for the physician of the future that Singapore needs.