Baylor College of Medicine
Houston, TX

Program Director: Jennifer A. Rama, MD
Type of Program: Pediatric Pulmonary Medicine
Abstract Authors: Jennifer A. Rama MD, Priya Garg MD, Dorene R. Balmer PhD

BACKGROUND
Enhancing teamwork skills among subspecialty fellows may enhance learning and is critical to leading a multidisciplinary medical team and demonstrating competencies required by the Accreditation Council for Graduate Medical Education (ACGME). However, fellows have limited opportunities to develop teamwork\ skills in a structured setting during fellowship. Team based learning (TBL) is an instructional method that allows the learner to apply current knowledge to new situations and to move away from just acquisition of facts. It is highly relevant to the practice of medicine as physicians routinely utilize critical thinking and function in multi-disciplinary teams. TBL has improved learning outcomes in large-scale undergraduate health sciences and residency settings yet has not been studied in smaller fellowship programs. The purpose of this project is to describe our experiences and process outcomes using a novel application of TBL during monthly board review in a pediatric pulmonology fellowship program.

METHODS
Previously, fellows conducted board review by giving a didactic lecture. After consulting with TBL experts, the program director (JR) implemented TBL in each of its 3 phases [1] Pre-class study phase; fellows read pertinent material prior to board review [2] Readiness assurance phase; fellows answer 5 more basic board questions individually and again as a team. Questions in this phase were more likely to involve straightforward recall. [3] Application of concepts phase; fellows answer 5 more difficult board questions in teams and simultaneously display the team’s consensus answers. Questions in this phase required more critical thinking and application of knowledge. (Table 1) The sequence of instruction allowed the fellow to progress through lower to higher levels of learning as designated by Bloom’s taxonomy.1 Three teams were formed based on continuity clinic assignments. Each team included one first, second, and third year fellow to match the level of training across teams and to promote clinic team identity and cohesiveness.

Fellows completed an evaluation survey prior to TBL implementation and after 1-, 6- and 15-months post TBL. We used Mann Whitney test to compare medians based on a likert-type scale. After 15 months, the fellows also completed the team performance survey2, an 18 item survey, previously shown to be valid and reliable among medical students.

RESULTS
Fellows (n=9) reported increases in critical thinking (p=0.01), test taking skills (p=0.01), group discussion (p=0.04), and interaction among colleagues (p=0.02) during the TBL format compared to lecture. These increases were sustained over 6 and 15 months. (graph1) The lowest scoring item on the team performance survey (scale 0 to 6) was peer feedback on team performance (4.83, SD +1.17 n=6). Otherwise, averages on the team performance survey were consistent with high quality team interactions and ranged from 5.33 (SD+0.82) to 5.8 (SD_+ 0.41) All fellows preferred TBL over lecture at 1-, 6- and 15-months post TBL.

CONCLUSIONS
TBL transformed board review from passive to active learning and was highly favored by fellows. TBL fosters skills useful not only for board preparation but also for developing the critical thinking and teamwork abilities of a competent physician. Future directions include monitoring for an effect on fellows’ scores on Subspecialty In-Training and Pulmonology Board examinations over time.

REFERENCES
1. Jim Simbley and Sophie Spirdonoff, ‘Why TBL Works’ <http://www.teambasedlearning.org/Resources/Documents/TBL%20Handout%20Aug%2016-print%20ready%20no%20branding.pdf> [Accessed December 1, 2014.]
2. B. M. Thompson, R. E. Levine, F. Kennedy, A. D. Naik, C. A. Foldes, J. H. Coverdale, P. A. Kelly, D. Parmelee, B. F. Richards, and P. Haidet, ‘Evaluating the Quality of Learning-Team Processes in Medical Education: Development and Validation of a New Measure’, Acad Med, 84 (2009), S124-7.

Table 1: TBL Application to a Pediatric Pulmonary Fellowship Board Review Course

³ Available from: http://www.epsteineducation.com/home/about/default.aspx

⁴ Parmelee, D.X. and L.K. Michaelsen, Twelve tips for doing effective Team-Based Learning (TBL). Med Teach, 2010. 32(2):p. 118-22