The lens of constructivist learning theory  provided a useful framework to understand student perspectives of classroom learning. Four major themes emerged: guided learning, problem solving, collaborative learning, and critical reflection. Students were attracted to the active and collaborative approach of TBL, perceiving the key advantages to be the small group size, the Readiness Assurance Testing process, facilitation by a clinician, an emphasis on basic science concepts, and immediate feedback. The TBL format proved powerful in fostering engagement and learning not always evident within other forms of small group work, such as PBL . However, students expressed a desire for increased opportunity for clinical reasoning within TBL.
According to constructivist theory, the focus of the learning should be on the student or learner rather than the teacher. The teacher’s role is that of an expert facilitator, to guide the students in taking an active learning role . By following the steps in TBL, one facilitator was readily able to manage four small groups of students simultaneously. Literature suggests that one content-expert facilitator can manage a class of 100 students placed in small groups . It is should be noted that student views on individual tutor performance may not reflect the effectiveness of any individual teaching approach. However, our students expressed preference for the provision of structured guidance, which is limited in PBL. Students noted that an advantage of TBL was the immediate feedback and guidance from the facilitator, despite having double the number of students in the class. Additionally, the Readiness Assurance Process provided the facilitator with a means to immediately assess students’ knowledge  and understanding, and address their specific needs. The importance of providing clinical relevance to medical teaching is frequently highlighted in medical education literature [19, 25]. Students felt that with an experienced senior clinician as a TBL facilitator, the feedback was accurate and clinically relevant.
Problem solving activities play a key role in engaging students. They need to be of work related relevance, and challenge prior concepts. Guidance from teachers and team members provides scaffolding for learners to build on prior learning . The primary learning objective in TBL methodology is to focus on ensuring students have the opportunity to practice using the core concepts to solve problems . However, in our iteration of TBL, this was deficient. An emphasis on physiology, the readiness assurance test and feedback, as well as time limitations, meant there were insufficient clinical reasoning opportunities within clinical problem solving activities. Our results indicate that while TBL offered advantages in terms of teaching physiology, opportunities were lacking for development of clinical reasoning skills. As noted by Parmelee (2010), significant effort is required to make the problem based activities useful, with an optimal degree of difficulty .
Students found that while the PBL format encouraged collaborative learning in groups, it was not uncommon for this learning to “go off on a massive tangent.” Students commented on feeling more actively engaged during TBL. This was due to two key elements, including the smaller group size, and the team readiness assurance tests. Completion of TBL tasks, such as tests and problem-solving, required productive team interaction . Additionally, in TBL, students reported feeling motivated to carry out individual preparation for the readiness assurance tests. In the TBL setting, there is little opportunity for individuals to avoid prior preparation and engagement in group activities [27, 28]. Students noted that they were more likely to come to class prepared in TBL, hence the quality of team and class discussions improved. However, in our study we did not have evidence for the stability over a long enough period for the team-development process to come to fruition [27, 29].
Opportunities for critical reflection are needed to allow students to make judgements on required modification to their existing knowledge . In TBL, the sequence of the Readiness Assurance Process ensured that students had several opportunities to engage with the content and gauge their own understanding . The tests encouraged self-reflection on knowledge, and also self-reflection on students’ own interactions between group members. Reflection occurred when students compared their understanding to that of their team members during the Team Readiness Assurance process. Students reflected on their own understanding when inconsistencies were exposed. Through discussion to agree on an answer, students were able “to see the thought process of other people”, and build one their own understanding. Although reflective practices also occurred through student interaction during PBL sessions, the formal testing procedures in TBLs promoted reflection.
In this qualitative study, we were able to explore in depth the rich experience of 14 students from a theoretical perspective. The six students who did not participate in the focus group may have had different opinions that were not captured by their peer participants. By timing the focus groups immediately following the TBL, we may have influenced students’ perceptions. If we had timed the focus groups at a later date, their views may have altered.
We acknowledge the design and format of both PBL and TBL in this study have been customised to run in a single institution. However, we believe our findings might be helpful to other medical schools investigating the introduction of TBL through pilot studies. We note that we did not provide a control group for the study, which may have provided greater depth to our data and findings.
We acknowledge that the facilitator was a senior medical practitioner and academic, with extensive teaching experience. This may have made the TBL experience more positive for our students (whose focus is on medicine) than might be the case if they were taught by a more junior basic science staff member.
Our study findings indicate that wider scale implementation of TBL, with further modifications is needed before a decision can be made on final changes to teaching methods. Further modifications would include: extended duration of TBL to allow more time for clinical reasoning; and prompts to facilitate clinical reasoning during the TBLs.