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Active learning, Cognition, Immunology, Medical education, IntroductionOver the last couple of decades, in majority of the medical schools worldwide, there was a paradigm shift in medical curricula from teacher-centered to learner-centered approach ( 1, - 2, ). Evidence suggests that teacher-centered approaches, where students are passive learners, are less appealing to the present millennial learners who are more digitally inclined and demand for more active and engaging learning environment ( 3, - 4, ). In contrast, student-focused active learning methods motivate learners, promote active participation, facilitate peer discussion, enhance communication, increase critical thinking and problem-solving ability, and thus foster knowledge retention ( 5, ). Rapid advancements in technology in recent years has led to the development and increased use of several student-focused, self-directed active learning approaches by medical educators ( 6, ). Problem-based learning (PBL), Patient-Oriented Problem Solving (POPS), Case-based learning (CBL), and Team-based learning (TBL) pedagogical strategies are some examples ( 7, - 10, ). Generally, the confidence of the students who learn through active learning modules is significantly high thus, delivery of medical training through student-focused learning approaches improves medical education and student learning outcomes ( 11, ). Team-based learning is relatively a new, highly structured, and evidence-based collaborative active learning strategy, well suited for small group learning sessions ( 12, ). It is an instructor-led student-centered pedagogy delivered through several sequential phases. Students hold accountability for in-class and out-of-class preparation and master course concepts by working collaboratively with peers under the instructor&,rsquo s frequent feedback ( 13, ). TBL is taught in three phases, pre-class preparation, in class readiness assurance testing, and knowledge application exercise ( 14, ). The pre-class preparation phase occurs before in-class TBL session. Students are required to study pre-reading material sent by the instructor in advance or attend flipped classroom lectures beforehand. This allows them to know the key learning issues and come prepared for the activity. In in-class TBL sessions, students are organized into a team of 5-6 members. At the beginning, students&,rsquo knowledge of the topic gained through pre-class preparation is tested by a set of questions (typically consisting of 10-20 questions single best answer, true/false, multiple select type), wherein students complete the test individually (iRAT or individual Readiness assurance test) without referring to any study material or discussion with other students. After all students complete iRAT, they work together on the same set of questions in their team (tRAT, team readiness assurance test). During tRAT, students in the team are allowed to discuss the answers. Following completion of tRAT, the team must reach consensus after discussion with members and submit their collective answers that they think are correct. The instructor then provides immediate elaborative feedback on their answers and clears the concepts that students do not get or find difficult. The knowledge application exercise phase follows tRAT. In this phase, students work on a given challenging clinical case scenario and apply the conceptual knowledge (application exercise) that they have learnt in iRAT and tRAT to understand and digest various aspects of the clinical case such as pathogenesis, diagnosis, and management strategies, and others. The instructors provide elaborative feedback on case-related problems and additional explanation to students&,rsquo queries. Finally, to motivate students, best student and team is acknowledged by considering the performance in iRAT, tRAT, and application exercise ( 12, - 13, ).Immunology is one of the basic science subjects included in the medical curricula. The course introduces medical students to various new terminologies and concepts pertaining to structure and function of the immune system, immunological diseases, pathogenic mechanisms, laboratory diagnosis, and management ( 14, - 15, ). Therefore, it is a challenge for medical students to learn and digest various concepts and correlate them to understand various aforesaid aspects of immunological diseases within a short period. Therefore, it is critical for immunology teachers to adopt a teaching method that promotes the students&,rsquo learning efficiently. Recently, at the College of Medicine and Health sciences (CoMHS), the curriculum was reviewed and reconstructed with an emphasis on active learning exercises. Team-Based Learning (TBL) method developed by Larry Michaelson in 1979 and used by medical educators across the globe was found to be suitable for small group session and was introduced into the immunology course ( 16, ). However, the present COVID-19 pandemic crisis resulted in closure of educational institutions. Continuation of education through virtual teaching by innovative learning and managing system became the need of the hour. Most of the educators have explored and found many effective e-teaching software to provide maximum possible benefits to students through online learning ( 17, ). Technology (InteDashboardTM and OpenTBLTM) designed to support all key areas of online TBL sessions, namely iRAT, tRAT, and application exercise, are currently available ( 18, ). E-learning wave is a recent development, and students are in the process of adapting to new teaching and learning methods. Therefore, it is essential to know the opinion of students and explore their inclination toward novel e-learning teaching methodology ( 19, ). On thorough literature search, we found a few TBL studies in immunology conducted through face-to-face sessions at the institute, but there were no studies on online TBL method. Thus, the current study aimed at introducing online synchronous TBL pedagogy in immunology course and exploration of students&,rsquo perception on effectiveness of online TBL in promoting their learning skills. MethodsThe present crossover interventional study was conducted at College of Medicine and Health Sciences (CoMHS), Oman. The study was approved by the Institutional Research and Ethics Committee [Approval no, NU/COMHS/EBC0001/2021) and conducted after obtaining an informed consent from all the participants. Study design TBL module used by several researchers was reviewed by subject experts, modified, and used in our study ( 8, , 13, , 14, ). The study design is depicted in Figure 1,. MD4 medical students enrolled in medical course during the academic year 2020-21 were included in the study. Due to COVID-19 crisis and institutional lockdown, the TBL activity was conducted on Cisco Webex (purchased by our institution) online platform through breakout sessions. TBL sessions were conducted on common immunological diseases viz. systemic lupus erythematosus (SLE), Rheumatoid arthritis (RA), and Anaphylaxis. All students were informed about the activity two weeks prior to the session. The orientation sessions were given to overview the learning outcomes and objectives, information about learning platform and breakout rooms, and essentials of TBL process, team formations, team dynamics, team responsibilities, and grading (Fig 1,). Figure 1. CONSORT 2010 Flow Diagram Sample size To find a difference of 3 in improvement of scores (post-pre) between TBL and control group with a pooled variance of 10, with a power of 80% and significance level of 5%, we found that the study needed a minimum sample size of 24 per group. The study was replicated four times to cover more participants as follows. The whole batch was divided into four groups, A, B, C, and D with 35 students in each, and each group was further divided into team of 6 members. TBL sessions on different topics for each group was conducted on prescheduled different dates and times. TBL sessions on Anaphylaxis, SLE-1, RA, and SLE-2 were scheduled for groups A, B, C, and D, respectively. During these TBL sessions, groups B, A, D, and C were considered as the control (self-study) groups, respectively (Fig 2,). Figure 2. Study design of TBL activity. TBL, Team Based Learning Execution of the TBL sessions TBL activity on anaphylaxis, Students in groups A and B were enrolled in the study and control groups (self-study), respectively. The pre-class preparation study material with detailed information such as general characteristics, triggering/risk factors, pathophysiology, clinical features, complications, laboratory investigations, and management plan on Anaphylaxis was sent to all the students of group A and B through their institutional email one week prior to the activity. On the day of the session, 10 minutes prior to the beginning of the session, two separate Cisco-Webex links were sent to the students in groups A and B. All of them were first asked to complete the pretest questions on anaphylaxis (comprising of 10 questions single best answer, true/false, and multiple select) sent by a google form to their institutional email within 15 minutes. Then, group B students (control group) were asked to do self-study individually on anaphylaxis at their home for 1 hour, while TBL session was conducted to group A students (study group). The group A students were divided randomly into teams comprising of 6 students in each team in Cisco-Webex break out rooms, and the TBL was conducted through standard sequential phases (Fig 3,). Figure 3. Illustration of sequential phases of TBL session. TBL, Team Based LearningThe pretest completed earlier by the study group individually to know the knowledge acquired by studying pre-class reading material was considered as individual readiness assurance test (iRAT). Following iRAT, students were allowed to discuss the pretest questions in a team (team readiness assurance test tRAT) for a period of 30 minutes. Upon completion, all teams were asked to submit their answers of tRAT questions after the collective decision of team members to the instructor&,rsquo s email. Subsequently, the instructor gave feedback immediately to the individual team by revealing correct answer to each question with an elaborative explanation. Other doubts and misconceptions of each team were also clarified by the instructor. After completion of tRAT, all teams were asked to discuss (for half-hour) a clinical case scenario on anaphylaxis with a set of designated questions (application exercise) which was sent through their institutional email. In the final half hour time, all students were removed from breakout sessions and brought under a single Cisco Webex platform and were asked to present their answers to the set of questions given along with the clinical case scenario. Finally, the instructor provided answers and additional explanations to case-related students&,rsquo doubts and misconceptions. For promotion of the students&,rsquo participation and motivation, the best student and team was acknowledged by considering iRAT, tRAT, and application exercise performances. At the end of the session, post-test questions were sent through google survey form the link to all the group A members as well as group B members (who did self-study at home during TBL session of group A) they were asked to submit their answers within 15 minutes. All pre-test and post-test scores were collected for statistical analysis.TBL activity on SLE and RA, Similarly, online synchronous TBL sessions for groups B, C, and D were carried out on separate pre-scheduled dates. Systemic lupus erythematosus topic was assigned and divided into two separate topics with different questions and clinical case scenario as SLE-1 and SLE-2. RA, SLE-1 and SLE-2 were the topics utilized for groups B, C, and D TBL sessions, respectively. Groups A, D, and C were the corresponding control groups for SLE-1, RA, and SLE-2 TBL sessions. At the end of each TBL session, pre-test and post-test answers of the study and control groups were collected and entered into Microsoft Excel sheet for statistical analysis.Finally, after completion of all the TBL sessions, the pre-designed, self-administered questionnaire validated for its contents and relevance by Microbiology &,amp Immunology, Medical education, and Medicine experts was used to get the feedback of the students regarding the effectiveness of online TBL activity in promoting their learning process. The link of the Google survey form of the questionnaire was sent to all the participants through their institutional email. The questionnaire was prepared on a 3-point Likert scale (agree, neutral, and disagree) on 12 items. All responses were collected for statistical analysis. Statistical analysis The students&,rsquo performances on pre-test and post-test were evaluated based on standardized answer keys. The improvement in scores following the sessions was calculated as dependent variables and these values were subjected to ANOVA using GLM, Repeated Measures in SPSS (statistical package for social sciences). The order in which the TBL and SS sessions were delivered was captured by a dummy variable using value 1 for SS-first and TBL-second, and 2 for TBL-first and SS-second. The model is set up as a repeated measures model defining a two-level within-subject factor (teaching mode). The results from the model are observed for the teaching mode and order in which the methods are delivered as explained earlier and a p-value for the F values are taken as significant if it is below 0.05. The profile plot is then used to find the ways in which these affect the improvement in scores.Students&,rsquo perceptions regarding the new method of teaching were assessed using a questionnaire with items giving responses as three categories of disagree [1], neutral [2], and agree [3]. Responses were converted into percentages agreeing on each item on the questionnaire. &,nbsp The opinion questionnaire had a Cronbach&,rsquo s alpha of 0.932, and all items were found to be valid and contributed equally to the overall opinion.ResultsIn total, 139 MD4 medical students of CoMHS of the academic year 2020-21 participated in the study. The cross-over nature of the educational intervention was tested for any interaction with the order as well as the teaching methods by repeated measures ANOVA. Table 1, shows improvements in post-test score from the pre-test score in various groups as per the order of delivery of teaching method. GroupOrderTBL to SSSS to TBLTotalTBLSSTBLSSTBLSSAMean&,plusmn SD5.26&,plusmn 1.461.37&,plusmn 1.66 5.26&,plusmn 1.461.37&,plusmn 1.66N3535 3535BMean&,plusmn SD. 4.91&,plusmn 1.092.77&,plusmn 1.524.91&,plusmn 1.092.77&,plusmn 1.52N 35353535CMean&,plusmn SD4.94&,plusmn 1.752.77&,plusmn 1.21 4.94&,plusmn 1.752.77&,plusmn 1.21N3535 3535DMean&,plusmn SD. 4.80&,plusmn 1.232.26&,plusmn 1.224.80&,plusmn 1.232.26&,plusmn 1.22N 35353535TotalMean&,plusmn SD5.10&,plusmn 1.612.07&,plusmn 1.614.86&,plusmn 1.162.51&,plusmn 1.394.98&,plusmn 1.402.29&,plusmn 1.51N70707070140140TBL and SS, F(1,137) = 321.309, p&,lt 0.0001, Period1 and Period2, F(1,137) = 5.236, p&,lt 0.05 |