This study marks the beginning of increasing the number of TBL sessions throughout the pre-clerkship curriculum as a major mode of active learning at TTUHSC SOM. The abbreviated TBL format presented here as an adaptable method aimed at enhancing student learning and examination outcomes. Several factors were critical to successfully implementing TBL in a medical school setting: The institutional culture supported instructional innovation, and students were receptive to the trial-and-error nature of a new strategy. The Pilot Phase of this study involved early-adopter faculty across different courses in the curriculum, who volunteered to host single, non-mandatory sessions. Additionally, a comparatively smaller number of students during this pilot phase allowed for feasibility testing and optimization of session parameters (e.g., quiz release times, number of items on quiz, time allocation for iRAT and tRAT).

The course leadership faculty for the Organ System 1 course in the Implementation Phase were also involved in the Pilot Phase, ensuring continuity. Faculty initiating TBL sessions were receptive to ongoing informal student feedback, leading to adjustments in session parameters as needed, particularly for larger numbers of learners. Normally, organizing a TBL module is resource intensive, but integration into the curriculum here was greatly facilitated by leveraging a question bank with a large number of MCQs iRAT or tRAT assembly, and access to a large classroom that accomodates small-group arrangements. We used a classroom with 40 six-seat tables (Fig. 1), each with an individual screen and large wall screens to guide the overall session. Students were observed in lively discussions with some groups using the available technology in this ideal facility for a small-group large classroom setting, and other groups using their personal tablets or laptops or paper to draw, share, and explain their answers. While our specific classroom setup and technology were ideal, any large room that supports small groups to interact and discuss and potentially spread out to reduce (noise) interference across groups would seem appropriate for this setting. Some well-attended sessions can get quite loud. In these situations, sessions can be scheduled in duplicate to split a large class size in half.

TBL sessions provide an opportunity for students to assess gaps in their understanding and share their concerns with peers and faculty. The peer pressure and natural deadlines for completing work inherent in TBL encourage students to avoid procrastination and engage in self-testing. In the TBL context, students may also realize that they are not the only student not knowing an answer and that even when all team members got an item on the iRAT wrong, they can still as a group come to the correct answer. TBL also reinforced the value of testing to identify weaknesses thereby supporting a growth mindset. We hypothesize that these benefits could have led to the observed higher NBME performance for students who participated in TBL sessions more often [24].

As importantly, we observed that students were learning how to work, interact, and collaborate in a team during the TBL sessions. Thus, TBL can help with integration of knowledge, while developing interpersonal and collaborative skills. For example, the development of communication skills was first encouraged during team test discussions in TBL and then by seeking feedback that allowed students to generate a scholarly formulated argument or a question. Finally, the students engaged in intra-team communication during tRAT. Working together in self-determined teams encouraged friendships that became instrumental in forming informal, outside-of-classroom, small study groups. These sessions also enabled students to develop closer collegial connections with their faculty that would be more difficult to achieve in a large lecture classroom setting. Studies have shown that developing such relationships with peers and faculty can be a safeguard against dropout [25].

In the medical field or the healthcare sector in general, there is a demand for students who can coordinate with others, engage in critical thinking, and demonstrate cognitive flexibility, emotional intelligence, complex problem-solving, judgment, and decision-making [26]. Several studies have shown that TBL, in contrast to the traditional one-way lecture format, meets these competency-based challenges [5, 27,28,29,30,31]. Thus, future iterations of the optimized TBL sessions will be consistently implemented within all Organ System Courses of the curriculum.

In this study, attendance and participation played a significant role in the effectiveness of TBL sessions. To respect faculty and students’ autonomy, sessions were offered as selectives, allowing learners to choose based on their needs. Although this study is based on a unique abbreviated adaptation of TBL, our results are consistent with previous studies demonstrating TBL’s positive impact on exam performance [30]. Additionally, similarly to traditional TBL, our abbreviated TBL still allowed learners to practice other skills essential to success in increasingly complex healthcare systems, like communication and collaboration. The effects of TBL reported here are subject to important qualifications, however. For example, further investigation in causality needs to be conducted to elucidate the relationship between higher scores on NBME and participation in TBLs. We entertain the possibility that high-performing students attended more TBLs since they had more time, while low-performing students chose self-study. We also hypothesize that high-performing students chose participation in TBLs for other non-scholastic benefits outlined earlier.

TBL proved resource efficient in digitally enabled classroom settings, reducing the amount of time to prepare compared to traditional lectures. Facilitators could easily content and questions to be discussed in class, for example, based on misconceptions revealed in small-group discussions.

Since most of the learning occurs in the form of discussions and feedback sessions in class, unnecessary detail and extensive preparation are minimized. Finally, TBL is scalable to much larger student-to-faculty ratios of 200 to 1 [32] and can be facilitated in large classroom settings. The quality of the discussion during completion of the tRAT depends on students’ motivation for in-depth dissection of each question. If students are free to leave the session early, they may rush to just complete the TBL. An additional consideration may be the impact of expertise of the facilitating faculty on the success of the TBL sessions. In several instances, faculty who led a session were not content experts for the respective TBL session content but highly supportive of the TBL format. The feedback in some sessions was limited to UWorld rationales. We did not find that this impacted the student experience for these sessions. With a more formal inclusion of the TBL format in our curriculum, TBL sessions will nonetheless be led by content experts.

TBL’s scalability allows for a large group of students to participate in small-group learning experiences, with a small number of faculty facilitators. Thus, introduction of TBL presents a resource-saving option in terms of required faculty. We believe that the benefits and the positive outcomes will be further multiplied as more TBL-specific technologies start to emerge aiding in gathering detailed data and further optimization of TBL sessions. In addition, we infer that institutions that adopt TBL or similar active learning strategies consistently will see improvements in student performance and engagement.

Transforming pedagogical practice is challenging, particularly for basic science and clinical science medical faculty with limited prior exposure to TBL pedagogical theory and training. Allowing for institution-specific adaptations and gradual implementation of TBL, as described here, may ease the transition from traditional lecture-centered approaches to active learning through TBL.

The study acknowledges several limitations. The small sample size of participating students during the pilot phase (24 students) may limit the generalizability of findings for this small cohort. Additionally, the study only evaluated short-term impacts of TBL, lacking longitudinal data to assess its effectiveness over time. TBL was only introduced and investigated within one organ section within a single course for the present study. Since participation was partially voluntary, the self-selection of motivated students may have biased the results. Inconsistencies in team composition across sessions could also have influenced outcomes due to varying team dynamics. We did neither control nor record team composition. The study lacks formal qualitative feedback on student motivation, which could have provided deeper insights. Additionally, not all faculty facilitators were content experts, potentially impacting the consistency of TBL sessions. Finally, familiarity with the same questions in iRAT and tRAT assessments might have inflated scores, affecting the measure of genuine learning improvements.