All first-year medical students enrolled in the Gastrointestinal, Human Nutrition, Endocrine, Reproduction (GIHNER) block participated in the hybrid format for problem-based learning (PBL).

There were 103 students in total over the two cohorts with more females (57%, n = 59) than males (43%, n = 44). The average age was 24 years and 10.7% (n = 11) of the cohorts had completed a master’s degree prior to enrolling in medical school. From the admission record, 1% (n = 1) were Native American/Pacific Islander; 19.4% (n = 20) were Hispanic/Latinx; 10.7% (n = 11) African American, Black, and/or Afro-Caribbean; 26.2% (n = 27) Asian; 42.7% (n = 44) White; 9.7% (n = 10) “other”; 2.9% (n = 3) were multiple races/ethnicity; while 7.8% (n = 8) did not reveal their ethnicity upon admission. Students were divided into groups of seven to eight learners per group, making 14 groups total (seven per cohort). Eighty-seven (84.47%) of the 103 students completed the survey.

Traditional PBL and IQ learning cases share a similar case design framework (see Appendix 1: General Framework for PBL/IQ Case Design), which allows for seamless creation of a hybrid format of the two styles. One popular example of traditional PBL (Table 1, column 1: Traditional PBL format) is a three-session case that runs on Monday, Wednesday, and Friday with the requirement that students continue to learn material related to the case between sessions.

At the start of the first session (session 1) of a PBL case, students receive information through sequential disclosure of parts of a story and they must determine pertinent information to the case [10]. From this information, they form hypotheses via a broad differential diagnosis and generate questions that span from their self-identified gaps in knowledge of basic and clinical sciences, pertinent patient history, and tests they would need to run to diagnose the patient and consider treatment strategies. They continue with this process through the first session of the case. The session ends with student generation of learning objectives based on the questions they asked during the session and, finally, feedback on self- and group performance. Between session 1 and the second session (session 2), each student takes responsibility for one student-developed learning objective by researching the content using relevant and vetted resources they identify and creating a short presentation for the group. During the first approximately half of session 2, students teach the objective they were responsible for to the other members of their group. During the second approximately half of session 2, students continue the case story through sequential disclosure, and they follow the steps they took in session 1 concluding with generation of learning objectives, and group and individual feedback. Between session 2 and the third or final session (session 3), students again prepare a presentation for an objective that was created in session 2. During session 3, students begin by presenting their learning objectives in the first approximately half of the session. In the second approximately half of the session, students receive the conclusion of the case story. Institutionally derived case objectives are revealed after the case conclusion so students can reconcile these and their student-generated learning objectives with institution-derived case objectives. The final feedback at the end of session 3, where there is formal discussion of individual and group performance, includes student self-evaluation of their performance determining the most important learning objectives in comparison to the institution derived case objectives.

For IQ learning (Table 1, column 2: Traditional IQ learning format), during session 1, students receive an entire case during approximately the first half of the session, and a second case during the approximate second half of the session. Instead of sequential disclosure of the case parts, students receive the whole case and pace themselves to complete the case within the allotted time. To assist students, IQ learning cases begin with a case goal, to help student groups have a little more focus in their thinking and learning objective creation without revealing too much information about the case before beginning the story. This provides support for students in IQ learning due to the nature of the IQ learning process being more rapid than the PBL process that will cover a case in multiple sessions.

During IQ learning, students are responsible for the steps covered in session 1 of PBL for each case, as described above, but they must complete identification of pertinent information, hypotheses through more refined differential diagnosis, asking case-relevant questions, and generation of learning objectives in approximately half the time as in PBL session 1. Prior to the end of IQ learning session 1, students have completed two cases, and have student-generated learning objectives for each. The session is concluded with student and faculty facilitator feedback on individual student and group performance.

In IQ learning, instead of each student being responsible for one objective generated in a session as in PBL, they are responsible to learn all of the objectives they created before attending the second and final session of the case (session 2). In a three-session model, the second session of three of IQ learning is centered around the first case of session 1 and the third session is centered around the second case of session 1. Significant variation exists between institutions as it pertains to structure of session 2 of a case, but the intent is for students to come to the session prepared by having learned the material associated with every student-generated learning objective they developed in session 1. During session 2, they review key concepts of the case while contributing to student-centered active engagement. The end of session 2, like in session 3 of PBL, ends with students reconciling their objectives with institution-derived case objectives, and finally individual and group feedback.

At NSU MD, between sessions 1 and 2 of IQ learning, the student leader of a case learns the material as the non-leaders do, but they will also determine for each objective the most important content for each objective followed by designing active learning activities for each objective. Leaders use their creativity to create a variety of active learning activities that they feel are best to cover each learning objective, including but not limited to publicly available online polling and adapted board games. The student leader has significant responsibility in that they invest more time with the objectives, develop a plan for session 2, and create different methods to engage the group to have them apply their learning of the student-generated learning objectives.

The PBL/IQ hybrid model (See Table 1, column 3: Hybrid PBL/IQ format) was designed to allow a significant amount of case information to be introduced in the PBL format for which students were well trained after having engaged in it for almost half of the pre-clerkship curriculum. In this format, students engage in one case over three sessions as they would in PBL, maintaining the number of cases and intended content, but providing a new format. The standard PBL format is used session 1 and the first approximately half of session 2. In the second approximately half of session 2, students receive the rest of the case, including the conclusion normally provided during PBL session 3. This is designed for students to manage the timing and pacing of the case the same session time constraints as they will have in IQ learning. Session 2 concludes with developing student-generated learning objectives and feedback. Session 3 of the PBL/IQ hybrid case is delivered similar to session 2 of a standard IQ learning case.

Before a student needs to independently act as a case leader in IQ learning, fulfilling the great responsibilities of a leader, the PBL/IQ hybrid teams two students as co-leaders so that they can better manage the time commitment and support each other in designing their active learning session. The feedback at the end of each PBL/IQ hybrid session contains focused questions (see questions provided as Supplemental Digital Appendix 2) that address student experiences as leaders and non-leaders including challenges and successful strategies they used, in the IQ format, so they can support and learn from each member of the group and receive advice from the faculty facilitator.

NSU MD employs four cases for the PBL/IQ hybrid format. This is based on group size to ensure that every student in a group has at least one chance to act as co-leader of a case before moving to standard IQ learning in the next course. This direct experience as a co-leader is complemented with student discussions at the end of each case where they reflect on their experiences and support each other with feedback and suggestions to address difficulties they had in the roles. Between the GIHNER and CPR course, and between PBL and IQ learning, a session is held with the students in a large group setting to provide review of the IQ format and active engagement with the whole class so that every group has a chance to discuss with other groups their experiences, and strategies they found to be successful in engaging in IQ learning.

Students formed new PBL groups of seven to eight members at the start of the GIHNER course and then participated in the hybridized PBL/IQ format for the final four of nine PBL cases. This allowed them to form a cohesive PBL group and then having four cases allowed all students to act as co-leader at least once. The final four cases followed the traditional 3 days per week format, but were modified to fit the novel hybrid approach.

During the subsequent course (Cardiovascular, Pulmonary, and Renal, known as CPR), students participated in a full IQ format for 19 cases. During the final week of the CPR course, students participated in the voluntary, anonymous survey to assess the perceptions of effectiveness of the PBL/IQ hybrid. Students were informed in advance that the voluntary survey would be given at the end of a CPR session to those who opted to participate.

The survey consisted of 19 questions, including a 5-point Likert scale, yes/no, and free response questions (full survey available as Supplemental Digital Appendix 3). Survey items assessed attitudes and preparedness of students for the IQ learning sessions, along with narrative free response for direct feedback on the hybrid model. Likert scale consisted of the following: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree. It was distributed through RedCap using electronic consent.

We used IBM SPSS 28.0 statistics package for data analysis. Descriptive statistics were used for demographic data. Pearson correlations and paired t-tests, with p < 0.05 were considered significant. We calculated Cronbach’s alpha to determine internal reliability of the survey questions.

This study was designated as exempt from the Nova Southeastern University Institutional Review Board (Protocol 2021–276-NSU).