The Facilitator Instrument for Team-Based Learning (FIT).

Construct: We sought to evaluate the quality of Team-Based Learning facilitation in both large and small group settings. Background: Team Based Learning (TBL) is an increasingly popular small group instructional strategy in health science education. TBL facilitation skills are unique and differ from those needed to lecture or facilitate other types of small groups. Measuring facilitation skills and providing feedback to TBL instructors is important, yet to date no valid instrument has been developed and published for this purpose. Approach: We created an 11-item instrument (ratings of each item on a 7-point scale) designed to assess TBL facilitation skills, considering major sources of validity. Twelve experts in TBL facilitation and training developed the content of the FIT. To ensure response processes were valid, we used an immediate retrospective probing technique with 4th year medical students who were not part of the study. The Facilitator Instrument for Team-Based Learning (FIT) was piloted with 2,840 medical students in 7 schools in large (year 1 and 2) and small (year 3) courses. The internal structure of the FIT was analyzed. Results: In total, 1,559 and 1,281 medical students in large and small TBL classes, respectively (response rate 88%) rated 33 TBL facilitators. The composite mean score for the FIT was 6.19 (SD = 1.10). Exploratory factor analysis and Cronbach's alpha indicated that all items loaded on 1 factor, accounting for 77% of the item variance. Cronbach's alpha for the 11 items was 0.97. Analysis of facilitator variables and course context indicated that FIT scores were statistically significantly correlated with type of class (pre-clinical or clinical) and size of class as well as the facilitator enjoyment in using TBL as a method. Gender and the amount that facilitators used TBL each year was weakly correlated, with other factors not correlated (years facilitating TBL, confidence in facilitating TBL, and age). Conclusions: Analysis of FIT scores from 2,840 medical students across multiple institutions and teaching settings suggests the utility of the FIT in determining the quality of TBL facilitation across a range of medical education settings. Future research is needed to further analyze course contexts and facilitator variables that may influence FIT scores with additional facilitators. Additionally, FIT scores should be correlated with additional measures of TBL facilitator quality, such as direct observations, especially if these data are used for summative decision-making purposes.

High-Stakes Collaborative Testing: Why Not?

Phenomenon: Studies of high-stakes collaborative testing remain sparse, especially in medical education. We explored high-stakes collaborative testing in medical education, looking specifically at the experiences of students in established and newly formed teams. APPROACH: Third-year psychiatry students at 5 medical schools across 6 sites participated, with 4 participating as established team sites and 2 as comparison team sites. For the collaborative test, we used the National Board of Medical Examiners Psychiatry subject test, administering it via a 2-stage process. Students at all sites were randomly selected to participate in a focus group, with 8-10 students per site (N = 49). We also examined quantitative data for additional triangulation. FINDINGS: Students described a range of heightened emotions around the collaborative test yet perceived it as valuable regardless if they were in established or newly formed teams. Students described learning about the subject matter, themselves, others, and interpersonal dynamics during collaborative testing. Triangulation of these results via quantitative data supported these themes. Insights: Despite student concerns, high-stakes collaborative tests may be both valuable and feasible. The data suggest that high-stakes tests (tests of learning or summative evaluation) could also become tests for learning or formative evaluation. The paucity of research into this methodology in medical education suggests more research is needed.

Team cohesiveness, team size and team performance in team-based learning teams.

OBJECTIVES: The purpose of this study was to explore the relationships among variables associated with teams in team-based learning (TBL) settings and team outcomes. METHODS: We administered the National Board of Medical Examiners (NBME) Psychiatry Subject Test first to individuals and then to teams of Year three students at four medical schools that used TBL in their psychiatry core clerkships. Team cohesion was analysed using the Team Performance Scale (TPS). Bivariate correlation and linear regression analysis were used to analyse the relationships among team-level variables (mean individual TPS scores for each team, mean individual NBME scores of teams, team size, rotation and gender make-up) and team NBME test scores. A hierarchical linear model was used to test the effects of individual TPS and individual NBME test scores within each team, as well as the effects of the team-level variables of team size, team rotation and gender on team NBME test scores. Individual NBME test and TPS scores were nested within teams and treated as subsampling units. RESULTS: Individual NBME test scores and individual TPS scores were positively and statistically significantly (p < 0.01) associated with team NBME test scores, when team rotation, team size and gender make-up were controlled for. Higher team NBME test scores were associated with teams rotating later in the year and larger teams (p < 0.01). Gender make-up was not significantly associated. CONCLUSIONS: The results of an NBME Psychiatry Subject Test administered to TBL teams at four medical schools suggest that larger teams on later rotations score higher on a team NBME test. Individual NBME test scores and team cohesion were positively and significantly associated with team NBME test scores. These results suggest the need for additional studies focusing on team outcomes, team cohesion, team size, rotation and other factors as they relate to the effective and efficient performance of TBL teams in health science education.

Team Emotional Intelligence, Team Interactions, and Gender in Medical Students During a Psychiatry Clerkship.

OBJECTIVE: This study examined the relationship between team emotional intelligence, quality of team interactions, and gender. METHODS: Psychiatry clerkship students participating in Team-Based Learning (TBL, n = 484) or no TBL (control, n = 265) completed the Workgroup Emotional Intelligence Profile (WEIP-S) and the Team Performance Scale (TPS). RESULTS: Significant correlations (p < 0.01) existed between quality of team interactions (i.e., TPS) and team emotional intelligence (i.e., WEIP-S) subscales, but not gender. Control and TBL groups experienced significant increases in WEIP-S subscales pre to post (p < 0.01, η (2) = .08), with the TBL group experiencing significantly higher gains in three of four subscales. Control group scored higher on TPS. CONCLUSIONS: A significant relationship exists between team emotional intelligence and quality of team interactions. Gender was unrelated to TPS or WEIP-S subscales. TBL group experienced higher gains in WEIP-S subscales while the control group experienced slightly higher TPS scores. Results suggest implications for medical educators who use TBL.

A Snapshot of Current US Medical School Off-Ramp Programs-a Way to Leave Medical School with Another Degree.

Although most students finish medical school, those who do not frequently have no obvious programmatic alternatives. In recent years, a growing number of medical schools have been developing "off-ramp" programs to help such learners. We surveyed 12 medical schools with off-ramp programs to understand their characteristics and challenges. Differences existed between programs but most were deemed helpful to the students and institutions they served. Advantages included the opportunity to acknowledge the students' hard work, increase career opportunities, and reduce debt. Understanding and promoting such programs will assist students for whom medical school does not represent the optimal career path.

Team-based learning in an undergraduate nursing course.

To increase student participation in the learning process, active learning methods, including small group learning, have become increasingly popular in modern curricula. One kind of small group learning, team-based learning, is a relatively new instructional strategy in health care education. Team-based learning uses theoretically based and empirically grounded strategies for ensuring the effectiveness of small groups working independently in classes with high student-to-faculty ratios (e.g., up to 200:1), without losing the benefits of faculty-led small groups with lower ratios (e.g., 7:1). To explore the effectiveness of this learning pedagogy, we evaluated students' level of engagement and attitudes toward the value of teams. Findings demonstrated that team-based learning is an effective teaching strategy for large groups of students.

Anxiety symptoms during pregnancy and postpartum.

This cross-sectional study compared the distribution of anxiety symptoms among pregnant, non-pregnant, and postpartum women of lower socioeconomic status. Participants were 807 women who were pregnant (24-36 weeks), postpartum (2-8 weeks), or not pregnant. Anxiety and depressive symptoms were assessed by the state-trait anxiety index and the Beck depression inventory, respectively. English and Spanish versions of the instrument were available. Group differences in anxiety were evaluated using analysis of variance. Multivariate regression was performed to evaluate differences in anxiety while controlling for marital status, education, race/ethnicity, employment, cohabitation, income, parity, history of depression/anxiety, and depressive symptoms. Anxiety scores were lower among postpartum women relative to pregnant and non-pregnant women (both P < 0.001), who did not differ (P = 0.99). After controlling for depressive symptoms and patient characteristics, anxiety remained lowest among postpartum women. Additionally, history of depression/anxiety and depressive symptoms were significant predictors of anxiety in the multivariate analysis. Comparatively low anxiety and depressive symptoms were observed among women who were 2-8 weeks postpartum. Anxiety symptoms that occur postpartum may not appear until later in the postpartum period.

Power in global health agenda-setting: the role of private funding Comment on "Knowledge, moral claims and the exercise of power in global health".

The editorial by Jeremy Shiffman, "Knowledge, moral claims and the exercise of power in global health", highlights the influence on global health priority-setting of individuals and organizations that do not have a formal political mandate. This sheds light on the way key functions in global health depend on private funding, particularly from the Bill & Melinda Gates Foundation.

Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature.

Medical and health sciences educators are increasingly employing team-based learning (TBL) in their teaching activities. TBL is a comprehensive strategy for developing and using self-managed learning teams that has created a fertile area for medical education scholarship. However, because this method can be implemented in a variety of ways, published reports about TBL may be difficult to understand, critique, replicate, or compare unless authors fully describe their interventions.The authors of this article offer a conceptual model and propose a set of guidelines for standardizing the way that the results of TBL implementations are reported and critiqued. They identify and articulate the seven core design elements that underlie the TBL method and relate them to educational principles that maximize student engagement and learning within teams. The guidelines underscore important principles relevant to many forms of small-group learning. The authors suggest that following these guidelines when writing articles about TBL implementations should help standardize descriptive information in the medical and health sciences education literature about the essential aspects of TBL activities and allow authors and reviewers to successfully replicate TBL implementations and draw meaningful conclusions about observed outcomes.

Psychiatry clerkship students' preparation, reflection, and results on the NBME Psychiatry Subject Exam.

OBJECTIVE: Psychiatry clerkship training involves many learning components, one of which is acquisition of scholarly knowledge. The authors investigate the reading materials and learning methods used by clinical clerks in their preparation for the National Board of Medical Examiners (NBME) Psychiatry Subject Exam (PSE). METHODS: Clerkship students from six U.S. medical schools who had recently completed their psychiatry clerkship and PSE were surveyed regarding reading material use, teaching methods encountered, and other relevant resources which may have influenced their PSE scores. RESULTS: The most frequently used PSE preparation material was a "step-or-prep" book, followed by practice questions, handouts, and assigned texts. No single preparation material type or combination proved significantly different in influencing PSE scores. The didactic methods used in clerkships did differ significantly in their influence on PSE scores. Students in the top quartile used slightly more books and different combinations of books than students in the bottom quartile. CONCLUSION: Students exhibited several trends in their preparation for the PSE. The most striking findings were the heavy student reliance on step-or-prep books over other learning resources and that step-or-prep books did not demonstrate significance as a superior preparation resource for the PSE. These trends in third-year psychiatric rotations have important implications for medical student education.

Evaluating the quality of learning-team processes in medical education: development and validation of a new measure.

BACKGROUND: Measurement of the quality of team processes in medical education, particularly in classroom-based teaching settings, has been limited by a lack of measurement instruments. Therefore, the purpose of this study was to develop and test an instrument to measure the quality of team interactions. METHOD: The authors created 30 items and reduced these to 18 items using factor analysis. They distributed the scale to 309 second-year medical students (RR = 95%) in a course that used teams and measured internal consistency, validity, and differences in scores between teams. RESULTS: Cronbach's alpha for the scale was 0.97. Team ratings were variable, with a mean score of 95.7 (SD 8.5) out of 108. Team Performance Scale (TPS) scores correlated inversely with the spread of peer evaluation scores (r = -0.38, P = .003). Differences between teams were statistically significant (P < .001, eta = 0.33). CONCLUSIONS: The TPS was short, had evidence of reliability and validity, and exhibited the capacity to distinguish between teams. This instrument can provide a measure of the quality of team interactions. More work is needed to provide further evidence of validity and generalizability.

Peer evaluation in a clinical clerkship: students' attitudes, experiences, and correlations with traditional assessments.

OBJECTIVE: The authors performed this study to determine whether clerkship peer evaluations, initiated as part of our "team-based learning" curriculum in 2002, correlated with other student performance measures, and to determine what qualities students rate in their peer evaluations. METHOD: The authors correlated peer evaluation scores with other student performance measures and performed a qualitative examination of student comments to assess reasons students gave for giving high and low scores. RESULTS: Peer evaluation scores correlated modestly with the National Board of Medical Examiners' (NBME) subject test, in-class quiz, and clinical scores. Qualitative comments demonstrated that students made assessments based on three thematic areas: personal attributes, team contributions, and cognitive abilities. CONCLUSIONS: Peers' evaluation scores modestly predict which students will perform well on other measures. However, there may be other qualities that are also important factors in peer evaluation. For example, most students value qualities of preparation and participation. Though students sometimes dislike peer evaluations, their assessments may enhance traditional course assessments and complement a comprehensive evaluation strategy.

Team-based learning at ten medical schools: two years later.

PURPOSE: In 2003, we described initial use of team-based learning (TBL) at 10 medical schools. The purpose of the present study was to review progress and understand factors affecting the use of TBL at these schools during the subsequent 2 years. METHODS: Representatives from 10 schools evaluated in 2003 were again evaluated in 2005. They were interviewed by members of the Team Based Learning Collaborative using a semistructured interview process. Data were analysed by 2 researchers using the constant comparative method and were triangulated through sharing results with other interviewers at regular intervals to verify conclusions and form consensus. RESULTS: TBL continued to be used in all but 1 school. At the 9 remaining schools, TBL was added to 18 courses, continued to be used in 19 and was discontinued in 13 courses. At some schools, it was discontinued in single courses in lieu of new, longitudinal integration courses in which TBL was a main instructional strategy. Faculty, student, course and institutional factors were associated with changes in TBL use. CONCLUSION: Faculty, administration/curriculum, students and characteristics of specific courses influence ongoing utilisation of TBL. Those who desire to implement TBL would do well to take these factors into account as they plan implementation efforts at their schools.

An evaluation of depressed mood in two classes of medical students.

OBJECTIVE: To assess depression rates in contemporary medical students. METHOD: The Beck Depression Inventory (BDI) was administered anonymously to two medical school classes at matriculation, the end of first year, and the end of second year. RESULTS: Median scores for both classes were low at all points. The proportion of students scoring in the moderate or severely depressed range increased from 5.8% at matriculation to 10.5% by end of Year 2 for the Class of 2004, and from 5.1% to 11.9% over the same time period for the Class of 2005. Overall, 75-83% of students at every administration scored in the lowest BDI score range. CONCLUSIONS: The percentage of medical students who experience depressed mood increased over time, but to a lesser degree than in previous studies.

Clinical grading in psychiatric clerkships.

OBJECTIVE: The clinical grade assessment is the most frequently used and heavily weighted component in the overall assessment of U.S. psychiatry clerkship students, yet the topic is understudied. The authors aimed to learn more about the nature, perceived virtues, and deficiencies of the clinical grade evaluation. METHODS: A 26-item questionnaire regarding the psychiatry clerkship clinical grading form was distributed to the clerkship directors of 129 medical schools in the U.S. and U.S. territories. The design of the document, its strengths, its weaknesses, grading outcomes, and utilization were assessed. RESULTS: Trends regarding clinical grading in psychiatry clerkships were detected. The clerkship grade form similarities, differences, desirable features, and utilization were ascertained, as were areas for improvement. CONCLUSIONS: The search for an optimal clinical grading process for the thousands of third-year medical students rotating annually is formidable. However, collaboration among psychiatry clerkship directors on development and improvement of clinical evaluation forms can clarify learning objectives and lead to better clinical evaluation tools.

Recruiting and rewarding faculty for medical student teaching.

OBJECTIVE: Finding time to teach psychiatry has become increasingly difficult. Concurrently, changes in medical student education are elevating demands for teaching. Academic psychiatry is challenged by these pressures to find innovative ways to recruit, retain, and reward faculty for teaching efforts. To address this challenge, the authors recommend a multifactorial approach to meeting the medical student educational mission of psychiatry departments. METHODS: This approach includes a variety of efforts including having Chairs serve as role models, enforcing the service requirements of volunteer faculty, expanding teaching venues, providing faculty development, elevating the status of teaching through academies, attending to promotion of faculty educators, establishing and nominating faculty for teaching awards, and using medical center resources to provide rewards for teachers. CONCLUSION: Academic leaders must acknowledge the inherent value of teaching to the academic enterprise and delegate sufficient resources to recruit, retain, and reward educators for the essential work that they perform.

The "shrinking" clerkship: characteristics and length of clerkships in psychiatry undergraduate education.

OBJECTIVE: The authors explored the time that is currently devoted to psychiatry clerkships to determine whether "shortened" clerkships differ in course director satisfaction and evaluation strategies. METHOD: An 18-item questionnaire was sent to 150 U.S. and Canadian clerkship directors. RESULTS: The return rate was 74% (111 questionnaires). Clerkship length ranged from 4 to 8 weeks, with 6 weeks being most common (49.5% of clerkships). Only 18.9% had clerkships lasting 8 full weeks. Shorter clerkships were more likely to rely on the NBME subject test, and less likely to rely on Objective Standardized Clinical Examinations (OSCEs) or oral examinations. Most clerkship directors (81.9%) felt their evaluation procedures reflected their clerkship objectives. Among those who did not or were not sure, a majority (77.7%) felt having too few weeks was among the causes, except for 8-week clerkship directors, who did not mention clerkship length as an issue. CONCLUSIONS: The number of clerkships having 2 full months devoted to psychiatry has decreased in recent years. Shorter clerkships rely heavily on the National Board of Medical Examiners (NBME) Subject Examination as an evaluation tool, testing for book knowledge rather than clinical skills.