MILITARY MEDICINE, 180, 4:64, 2015
Using Concept Maps in a Modified Team-Based Learning Exercise CAPT Barbara E.C. Knollmann-Ritschel, MC USN; Steven J. Durning, MD, PhD
ABSTRACT Medical school education has traditionally been driven by single discipline teaching and assessment. Newer medical school curricula often implement an organ-based approach that fosters integration of basic science and clinical disciplines. Concept maps are widely used in education. Through diagrammatic depiction of a variety of concepts and their specific connections with other ideas, concept maps provide a unique perspective into learning and performance that can complement other assessment methods commonly used in medical schools. In this innovation, we describe using concepts maps as a vehicle for a modified a classic Team-Based Learning (TBL) exercise. Modifications to traditional TBL in our innovation included replacing an individual assessment using multiple-choice questions with concept maps as well as combining the group assessment and application exercise whereby teams created concept maps. These modifica tions were made to further assess understanding of content across the Fundamentals module (the introductory module of the preclerkship curriculum). While preliminary, student performance and feedback from faculty and students support the use of concept maps in TBL. Our findings suggest concept maps can provide a unique means of determining assessment of learning and generating feedback to students. Concept maps can also demonstrate knowledge acquisition, organization of prior and new knowledge, and synthesis of that knowledge across disciplines in a unique way providing an additional means of assessment in addition to traditional multiple-choice questions.
INTRODUCTION For m any decades, m edical school education has centered around single discipline teaching and assessm ent. M any leaders in m edical education are now calling for m ore thor ough integration o f basic science and clinical aspects of m edical school edu catio n .1 A lthough m any m edical schools have recently m oved to a m ore integrated curriculum , such as organ-based in w hich m ultiple disciplines coordinate instruc tion around an organ system , assessm ent often rem ains a collection o f questions from these separate disciplines gath ered into one exam ination rather than evaluating the synthe sis o f a group o f related ideas across disciplines. Concept m aps can be used to stim ulate group discussion as well as potentially facilitate the integration o f basic science and clin ical education. C oncept m aps also provide a potential m eans to assess how students synthesize inform ation across disci plines and professions. T eam -based learning (TBL) exercises are widely used in education. They w ere introduced by M ichaelsen et al2 and also described by M illis and C ottell,3 w here they described structured learning team s that are developed in the classroom and sequenced assignm ents that allow students to apply or internalize the m aterial being taught. In TBL exercises, a prim ary objective is “to go beyond sim ply covering content and focus on ensuring that students have the opportunity to practice using course concepts and to solve problem s.”4 TBL is based upon a num ber o f key ideas. First, group w ork is
Department of Pathology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20186. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. Government. doi: 10.7205/MILMED-D-14-00568
64
central for the students to understand and apply course content. Second, the m ajority o f exercise tim e should be spent on group activities, w here students are given exam ples to work through and apply w hat they have learned, and lastly group activities allow students to im prove learning and develop self-m anaged learning team s over tim e such that the small group learns the strengths o f each team m em ber. Thus, the TBL form at is easily applied for problem -based learning type o f instruction. N ext, we describe concept m aps and TBL in m ore detail.
Concept Maps A ccording to N ovak and G ow in’s original w ork,5 “a concept m ap is a schem atic device for representing a set o f concept m eanings in a fram ew ork o f propositions.” Concept m aps are graphic representations to depict understanding o f the m ean ing o f a set o f ideas and how the ideas are linked together6-8 (the latter through the use o f specific linking w ords as shown in a concept m ap exam ple in Fig. 1). In other w ords, concept m aps are a potential tool for illustrating both depth (num ber o f related ideas) as w ell as organization (how the ideas are interconnected) o f know ledge. The latter is particularly diffi cult to assess with m ultiple-choice questions (M CQs) and a learner can sum m arize and analyze their ideas as well as visualize their thinking. Concept m aps have been used as an assessm ent tool o f learning in m any educational areas, and have potential for increased use in m edical education.9 A con cept map published by N ovak and C an as10 with explanation can be viewed at http://cm ap.ihm c.us. The concept map can be used for individual study and form ative assessm ent as sum m arized by D aley and T o rre ." U sing the concept m ap could help faculty to evaluate stu dent ideas and connections (breadth and o rganization of
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
fc o n c e p t map
shows : represenation
^K now led ge Aquisition ^
^ Organized th o u g h tj
^ New Knkowedge j
^E xisting Knowedge j
FIGURE 1. A concept map. A general graphic display of a concept map using the free software from http://cmap.ihmc.us. Concepts are contained in the boxes, whereas the unboxed words are the linking words that tell the reader how the concepts are linked together.
knowledge) in a detailed manner, providing a visual display of a student’s conceptualization for assessment. Concept maps are based on established learning theory and have been found to be effective in multiple disciplines outside of medicine.12 9 Concept maps can also be used to foster interdisciplinary understanding of scientific concepts, link understanding of science and clinical concepts, and inter professional understanding of teams and their relational func tions for clinical care. Without a visual tool and curriculum that supports the synthesis of ideas and relationships that the tool requires, students may not otherwise make such needed interdisciplinary connections. Concept maps require the learner to graphically represent not only the level of detail that he/she understands about spe cific topics, but also how each specific topic is important and linked to and through multiple disciplines such as biochemistry, pathology, microbiology, and physical examination findings. With MCQs, students may recognize an answer or be able to reason through the question and eliminate choices. With a concept map, students can demonstrate both understanding and breadth of knowledge as well as how ideas interconnect (knowledge organization). Furthermore, this can be demon strated between subject matter and disciplines. An example of using linking words is shown in Figure 2. Team-Based Learning In the classic TBL exercise, students are given preparation material to study ahead of the session. At the start of the TBL session, students are given an individual readiness assess ment test (/RAT) to evaluate their own preparation for the exercise. This is followed by a group readiness assessment test ("RAT) where the group needs to agree on the correct answer of the same quiz that was just given. Here, the content for the gRAT and exercise is discussed in greater detail in the
MILITARY MEDICINE, Vol. 180, April Supplement 2015
needed fo r
E m bryo lo g y
FIGURE 2. How linking words relate topics and integrate disciplines. Diagram showing how linking words relate topics to tell the reader of how they connect the topics. In addition, this examination shows how one can begin to relate a topic, such as the cell cycle to different disciplines such as Embryology and neoplasia (Pathology).
groups. As students discuss their interpretation of the material and come to a group agreement of what the correct response to the group quiz questions are, they deepen their learning and understanding of the material. Feedback is given by group members in the discussion of the material during the quiz or by the instructor as they move between the groups during the application exercise. In terms of assessment, individual scores are generated for the /RAT. All the group members receive the same score for the gRAT. Typically, the /RAT and gRAT assessments are MCQs. The students then work through an exercise (applica tion) where they typically apply the principles learned in the preparation material to examples or problems to further their understanding of the material. In this innovation, we replaced MCQs with concept map ping; students construct concept maps as the /RAT (individual maps) and gRAT (group maps), and the gRAT and application are combined in one exercise. In this article, we describe how we designed this modified TBL exercise around the use of concept maps and present preliminary results and next steps.
METHODS This innovation occurred during their first module at our medical school, the Fundamentals module (http://www .usuhs.mil/curriculum/pdf/CRNewClassof2018.pdf). In this
65
Using Concept Maps in a Modified Team-Based Learning Exercise
module, 14 individual courses are represented and present the foundations of their courses in this integrated module. The material presented has a specific science theme for each of the 7 weeks of instruction. Students were asked to review module material for their upcoming module final examina tion as their preparation for this modified TBL exercise, as we wanted to use this exercise as a review session, or “put ting it all together” for the Fundamentals module, thus the preparation was to “study for the final examination” of the Fundamentals module.
The Modified TBL Session The students were seated in small groups of 5 to 6 students per group, typical of a classic TBL session. A student was designated as the team leader for each group and he/she was responsible for ensuring the quizzes and group exercises were appropriately carried out and they distribute the /RAT and gRAT directions from the material in a folder on each table. The /RAT was given first to the students. The /RAT instructions were to create an individual concept map using the topic of “inflammation.” Students were instructed to include anything they had learned in the module to the concept of “Inflammation.” Students were given approximately 20 minutes to complete the /RAT (individual concept map). The team leader collected the /RAT papers into the folder. Following the /RAT students proceeded to the »RAT. Team leaders were instructed to distribute the combined yRAT and application activity sheets. These two items (yRAT and appli cation activity) were the same in our exercise; however, they are separate parts of a typical TBL. In this exercise, students were instructed to create a group concept map in which they needed to use 30 concepts pulled from topics instructed in the Fundamentals module and show how they relate to one another. They could use any of the 30 topics as their starting topic for the concept map, such as inflammation, which they were just given for their individual concept map. They were given a large piece of paper, such as from a flip chart, and were told they could add more sheets of paper if needed. Students were also told they could add any additional topics from the module, but at a minimum they needed to use the 30 concepts from the Fundamentals module given to them. Students were given approximately 75 minutes to work. Students were given feedback during this application por tion of the exercise by faculty who rotated around the tables as soon as the group exercise began. Faculty specifically encour aged students to include linking words and cross-links.13 The linking words tell the reader how the student links two con cepts together. For example, the concept inflammation can be divided into acute and chronic inflammation. The linking word between inflammation and acute could be “can be,” so the reader would follow that inflammation “can be” acute, and so forth. Cross-links are links that span between concepts of one arm or branch of the concept map to another arm or branch. This shows a higher level of learning from the student when they realize that concepts link across broader areas. A modified
66
I
© FIGURE 3. Sample Individual Concept Map. Typical concept map from a student working individually given the topic of inflammation and asked to include concepts from all disciplines studied in the Fundamentals module. Concept maps vary greatly between students as they show how each student individually links the concepts together.
example of an individual concept map produced during this exercise using inflammation as the starting concept is given in Figure 3.
Student Grading Grading of /RAT or individual concept map was performed by two graders independently as there is subjectivity to grading. Elements taken into account for grading included the amount of content and accuracy of content included in the concept map, whether students used linking words and cross-links. In our exercise, we wanted the students to get beyond acute and chronic inflammation and include the predominant cell types in each of these types of inflammation, and how inflammation is related to immunity, mediators of inflammation, and so forth to receive full credit for content for this individual quiz. Grading of the group maps was done by a primary reviewer, with a second reviewer reviewing all the concept maps and providing a second opinion for the maps that were between two grades. The two reviewers then jointly discussed any concept maps where the opinion differed in grading, and came to a consensus grade. Group maps were set up a little differently than the individual concept maps as the students had the list of the 30 topics that needed to be included in the group concept map. The list was provided to provide an anchor for student discussion, structure to this new group
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
exercise, and to facilitate evaluation. Thus, to receive full credit for content, all of these 30 items needed to be included in the concept map. Students were encouraged to add addi tional concepts beyond these 30 that were given to them, and the majority of the groups did this as well. Grading of the individual and group concept maps was done on a 2-point scale (pass or fail). This description of an educational inno vation does not include actual data from research participants nor does it involve patient or other sensitive data. PRELIMINARY RESULTS We collected preliminary data on our modified TBL activity. We will begin with discussing grading and then will present our feedback findings. G ra d in g
Individual and group concept maps were evaluated as above for content (knowledge of concepts), use of linking words, and the use of cross-links (knowledge organization and inter relationships of concepts) in the assessment of the concept maps both in the /RAT and gRAT exercises. Quality of both the individual and group maps varied. The group concept maps or gRATS were generally of high quality as students received feedback during the session from faculty as described above and were encouraged to include linking words, cross-links and additional topics if they had not already done so. Additionally, group maps involved student discussion, students had more time to complete the exercise, and for the group activity, they were given a list of 30 concepts to include in their maps. Individual concept maps demonstrated less detail and organization than the group maps, meaning these individual concept maps included less information and did not have as many linking concepts from multiple disciplines that were taught in the Fundamentals module. For example, individual concept maps were often divided into acute and chronic inflammation, and included the basic cell types seen in acute and chronic inflammation, but did not include many other topics from the Fundamentals module. On the other hand, the group concept maps were much more complex concept maps that included more detail and organization compared to the individual concept maps as these maps needed to include the 30 concepts given in the group exercise. To link these 30 concepts, the students had to work together and think broadly about all material presented in the Fundamentals module. The 30 concepts given to the students to be used to construct the group maps were pulled from topics presented by the 11 different courses that were taught in the Fundamen tals module. These courses included basic sciences (Biochem istry, Histology, Embryology, Microbiology, Pharmacology, Immunology, and Pathology) as well as the clinical sciences (Patient Interviewing, Physical Examination, Patient Safety, and Psychology). The group maps, in addition to having more concepts, were of higher quality as they all included
MILITARY MEDICINE, Vol. 180, April Supplement 2015
linking words and many groups had created cross-links that spanned among the different concepts and across traditional disciplines furthering their understanding of the integration of the individual courses and the basic and clinical sciences. A modified example of a typical group concept map from this exercise is shown in Figure 4. F a c u lty a n d S tu d e n t F e e d b a c k
Faculty observed that students were very involved in the group concept map exercise and that it was hard to stop the group discussions at the end of the session. Students used the entire time, which was 75 minutes, to work on the group concept maps. Faculty commented that students were actively engaged in discussing the concepts assigned, and discussing how the various concepts best are linked together. At times, they were able to link the concepts directly, other times, they linked the concepts by adding additional concepts from the Fundamentals module that were not on the list given to them in the instructions. Faculty members who had taught in the Fundamentals module had opportunities to review some or all the student group concept maps. Faculty were surprised to see the variety of topics chosen by the students as the starting point for their group concept maps, and how the students integrated their specific course with other material in the Fundamentals module, both in the basic and clinical sci ences. Faculty who taught in the Fundamentals module who reviewed these group concept maps had a unique glimpse into how the students organized the material presented to them in a unique way and provided an opportunity for these faculty members to self-reflect on how they presented their material in the context of other material in the module. Student feedback has been largely positive. Several stu dents provided positive feedback regarding the value of this exercise, and started to use concept maps regularly as part of their individual learning and study habits. In a few instances, students have commented that using the concept maps has refined their understanding of topics and has significantly helped them achieve higher scores on traditional MCQ exam inations. Students felt that there was sufficient time in the exercise to complete the individual and group concept maps. The next steps for the faculty are to improve the precision of grading, as there is individual variation in how the knowledge is organized and the amount of detail provided in some of the topics in the concept maps. NEXT STEPS Based in part on the preliminary success of this innovation, concept maps are now being used in multiple additional modules during the preclerkship timeframe. We have observed that students who create a less detailed concept map than they had constructed earlier in the curriculum often have poor study habits. As shown in Figure 5, a modi fication of a concept map for the Cardio-Pulmonary-Renal examination that is much more linear (i.e., less branching)
67
Using Concept Maps in a Modified Team-Based Learning Exercise
( T h e C e ll ]
/ \
A u t o im m u n e D is o r d e rs
____ _____ J \
(------------------------------—
can cau se
c o n t a in s \
\
has ----------- \
[ C e llu la r C o m p o n e n ts
[ D N A } r e p lic a te d d u r i / C e ll C y le 1
y
j
\
i
v----------------------'
can be
y
[in h e r ite d
—
q
\ r
can be
,, b e — [ M u ta te d ]
1
/ c a n le a d to
j
f D am aged
/
I
a n g i o g e n e s i s — [ N e o p la s ia j
c a n le a d t o
r e p a ir e d b y
A u t o i m m u n e D is o r d e r s [ Enzym es c a n le a d to
\
f H y p e r s e n tltlv lty
[ is a n
Ig E
s u c h a s — [ A n tib o d ie s )
N Type 1
j
p ro d u c e d by m ake
f B L y m p h o c y te s
[ A d a p tiv e c h a n g e ^
, ty p e
I
/
a c tiv a te d th ro u g h
m a y ln d u c e
[ In f la m m a t io n j
I tr ig g e r s fr o m
I [ In fe c tio n j \ tre a te d b y
[ M e t a b o liz e d
j
* m ust be
y
[ D ru g s j — a re
[E lim in a te d
j
“r
ir e s c r ib e d
- I s r e la te d to - > [ Q u a lity H e a lth C a r e
j
e v a lu a te d b y
rz ~ ~ h ( P a tie n ts ) —
e v a l u a t e d w i t h ------------ >
-----------> I P h y s ic a l E x a m
f P a tie n t S a fte y 1 l
)
FIGURE 4. Sample Group Concept Map. A group concept map excerpt from our exercise where the students were given 30 concepts that needed to be linked together. In this process, students discussed how topics from different courses are integrated and inter-related.
than expected.13 This concept map, when examined at a basic level, looks like “rain” streaming down in a linear fashion and does not show the level of branching or cross-links that we would expect to see in a learner who is continuing to acquire and organize knowledge on a topic. Further, poor
68
performance on a concept mapping exercise appears to corre late with poor performance on future examinations relating to the topic. Thus, we believe, concept maps may be a useful indicator of students who are in academic difficulty and can be used as a starting point to discuss individual learning
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
t ^ C or Pulm onale
FIGURE 5. Linear Concept Map. Concept map showing a "rain” pattern of linear thinking. This is not the typical branching pattern that is expected in concept maps and does not have cross-links indicated.
habits and help students visualize where their understanding may need to improve. In addition, reviewing the concept map provides a unique lens in assessment by seeing the graphic display of topics of the concept maps and how the students understand how these topics are related and inter-related. As faculty recog nize the value of seeing this type of integrated assessment, they have been willing to add concept maps as part of the faculty-derived assessment at the midterm or end-of-module faculty-derived examinations. Concept maps may also be a means to assess group per formance as group concept maps provided a method for the students to engage each other in topics, work together in a team to discuss how the topics are inter-related, and quiz each other on the topics to review for the examination as the exercise was initially designed as a review session. Concept maps can also be used to evaluate a curricu lum. Concept maps not only engage the students to think interdisciplinary, but also can be reviewed by the faculty to evaluate how the students see course material relating and integrating with other course material. This provides a unique perspective to the curriculum and integration, which are not easily captured in traditional MCQs. We have used the group concept maps to make enhancements to our own curriculum. CONCLUSIONS Modifying a TBL exercise as a basis for practicing how to create concept maps is a novel exercise allowing faculty to assess both knowledge and its organization in students, while students can explicitly see and practice the integration of concepts across the basic and clinical sciences that may not
MILITARY MEDICINE, Vol. 180, April Supplement 2015
be apparent through other types of exercises. The modified TBL format allowed the students the opportunity to first create their own individual concept map, then work together in a team to discuss the concepts being used, how they inter relate, and how to best display this integration of topics in a graphic form in the group concept maps. Using concept maps as a means of TBL assessment provides a means of assessing both student knowledge and their knowledge organization, which is not evident in traditional MCQs typically used in an /RAT or gRAT. Following student concept maps over time may alert the faculty to students who may have learning difficulties with a unique lens that may provide more insight than the limited data provided by a score on a multiple-choice examination. Concept maps created by students show the student perspec tive of how topics are integrated across the basic and clinical sciences and can be used to aide faculty in furthering integra tion of topics across multiple disciplines increasing integra tion in medical education. REFERENCES 1. Cooke M, Irby DM, O’Brien BC: Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey Bass, 2010. 2. Michaelsen LK, Watson WE. Black RH: A realistic test of individual versus group consensus decision making. J Appl Psychol 1989; 74(5): 834-9. 3. Millis BJ, Cottell PG: Cooperative Learning for Higher Education Faculty. Phoenix, AZ, Oryx Press, 1998. 4. Michaelsen LK, Sweet M: The essential elements of team-based learning. Chapter 1, In: New Directions for Teaching and Learning, pp 7-27. Edited by M.Wehlburg Catherine. Wiley, 2008. 5. Novak JD. Gowin DB: Learning How to Learn. New York, NY, Cambridge University Press, 1984.
69
Using Concept Maps in a Modified Team-Based Learning Exercise 6. Novak JD: Learning, Creating and Using Knowledge. Concept Maps as Facilitative Tools in Schools and Corporations, London, Erlbaum Associates, 1998. 7. Novak JD: A Theory of Education. Ithaca, New York, NY, Cornell University Press, 1977. 8. Novak JD: Concept maps and Vee diagrams: two metacognitive tools to facilitate meaningful learning. Instr Sci 1990; 19: 1-25. 9. Daley BJ, Conceigao S, Mina L, Altman BA, Baldor M, Brown J: Concept mapping: a strategy to support the development of practice, research and theory within human resource development. Human Resource Dev Rev 2010; 9(4): 357-84.
70
10. Novak JD, Canas AJ: The Theory Underlying Concept Maps and How to Construct Them. Technical Report IHMC CmapTools 2006-01 Rev 01-2008. Pensacola, FL, Florida Institute for Human and Machine Cognition, 2008. 11. Daley BJ, Torre DM: Concept maps in medical education: an analytical literature review. Med Educ 2010; 44(5): 440-8. 12. Daley BJ, Shaw CR, Balistrieri T, Glasenapp K, Piacentine L: Concept maps: a strategy to teach and evaluate critical thinking. J Nurs Educ 1999; 38: 42-7. 13. Torre DM, Duming SJ, Daley BJ: Twelve tips for teaching with concept maps in medical education. Med Teach 2013; 35: 201-8.
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Using Concept Maps in a Modified Team-Based Learning Exercise CAPT Barbara E.C. Knollmann-Ritschel, MC USN; Steven J. Durning, MD, PhD
ABSTRACT Medical school education has traditionally been driven by single discipline teaching and assessment. Newer medical school curricula often implement an organ-based approach that fosters integration of basic science and clinical disciplines. Concept maps are widely used in education. Through diagrammatic depiction of a variety of concepts and their specific connections with other ideas, concept maps provide a unique perspective into learning and performance that can complement other assessment methods commonly used in medical schools. In this innovation, we describe using concepts maps as a vehicle for a modified a classic Team-Based Learning (TBL) exercise. Modifications to traditional TBL in our innovation included replacing an individual assessment using multiple-choice questions with concept maps as well as combining the group assessment and application exercise whereby teams created concept maps. These modifica tions were made to further assess understanding of content across the Fundamentals module (the introductory module of the preclerkship curriculum). While preliminary, student performance and feedback from faculty and students support the use of concept maps in TBL. Our findings suggest concept maps can provide a unique means of determining assessment of learning and generating feedback to students. Concept maps can also demonstrate knowledge acquisition, organization of prior and new knowledge, and synthesis of that knowledge across disciplines in a unique way providing an additional means of assessment in addition to traditional multiple-choice questions.
INTRODUCTION For m any decades, m edical school education has centered around single discipline teaching and assessm ent. M any leaders in m edical education are now calling for m ore thor ough integration o f basic science and clinical aspects of m edical school edu catio n .1 A lthough m any m edical schools have recently m oved to a m ore integrated curriculum , such as organ-based in w hich m ultiple disciplines coordinate instruc tion around an organ system , assessm ent often rem ains a collection o f questions from these separate disciplines gath ered into one exam ination rather than evaluating the synthe sis o f a group o f related ideas across disciplines. Concept m aps can be used to stim ulate group discussion as well as potentially facilitate the integration o f basic science and clin ical education. C oncept m aps also provide a potential m eans to assess how students synthesize inform ation across disci plines and professions. T eam -based learning (TBL) exercises are widely used in education. They w ere introduced by M ichaelsen et al2 and also described by M illis and C ottell,3 w here they described structured learning team s that are developed in the classroom and sequenced assignm ents that allow students to apply or internalize the m aterial being taught. In TBL exercises, a prim ary objective is “to go beyond sim ply covering content and focus on ensuring that students have the opportunity to practice using course concepts and to solve problem s.”4 TBL is based upon a num ber o f key ideas. First, group w ork is
Department of Pathology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20186. The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of Defense or the U.S. Government. doi: 10.7205/MILMED-D-14-00568
64
central for the students to understand and apply course content. Second, the m ajority o f exercise tim e should be spent on group activities, w here students are given exam ples to work through and apply w hat they have learned, and lastly group activities allow students to im prove learning and develop self-m anaged learning team s over tim e such that the small group learns the strengths o f each team m em ber. Thus, the TBL form at is easily applied for problem -based learning type o f instruction. N ext, we describe concept m aps and TBL in m ore detail.
Concept Maps A ccording to N ovak and G ow in’s original w ork,5 “a concept m ap is a schem atic device for representing a set o f concept m eanings in a fram ew ork o f propositions.” Concept m aps are graphic representations to depict understanding o f the m ean ing o f a set o f ideas and how the ideas are linked together6-8 (the latter through the use o f specific linking w ords as shown in a concept m ap exam ple in Fig. 1). In other w ords, concept m aps are a potential tool for illustrating both depth (num ber o f related ideas) as w ell as organization (how the ideas are interconnected) o f know ledge. The latter is particularly diffi cult to assess with m ultiple-choice questions (M CQs) and a learner can sum m arize and analyze their ideas as well as visualize their thinking. Concept m aps have been used as an assessm ent tool o f learning in m any educational areas, and have potential for increased use in m edical education.9 A con cept map published by N ovak and C an as10 with explanation can be viewed at http://cm ap.ihm c.us. The concept map can be used for individual study and form ative assessm ent as sum m arized by D aley and T o rre ." U sing the concept m ap could help faculty to evaluate stu dent ideas and connections (breadth and o rganization of
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
fc o n c e p t map
shows : represenation
^K now led ge Aquisition ^
^ Organized th o u g h tj
^ New Knkowedge j
^E xisting Knowedge j
FIGURE 1. A concept map. A general graphic display of a concept map using the free software from http://cmap.ihmc.us. Concepts are contained in the boxes, whereas the unboxed words are the linking words that tell the reader how the concepts are linked together.
knowledge) in a detailed manner, providing a visual display of a student’s conceptualization for assessment. Concept maps are based on established learning theory and have been found to be effective in multiple disciplines outside of medicine.12 9 Concept maps can also be used to foster interdisciplinary understanding of scientific concepts, link understanding of science and clinical concepts, and inter professional understanding of teams and their relational func tions for clinical care. Without a visual tool and curriculum that supports the synthesis of ideas and relationships that the tool requires, students may not otherwise make such needed interdisciplinary connections. Concept maps require the learner to graphically represent not only the level of detail that he/she understands about spe cific topics, but also how each specific topic is important and linked to and through multiple disciplines such as biochemistry, pathology, microbiology, and physical examination findings. With MCQs, students may recognize an answer or be able to reason through the question and eliminate choices. With a concept map, students can demonstrate both understanding and breadth of knowledge as well as how ideas interconnect (knowledge organization). Furthermore, this can be demon strated between subject matter and disciplines. An example of using linking words is shown in Figure 2. Team-Based Learning In the classic TBL exercise, students are given preparation material to study ahead of the session. At the start of the TBL session, students are given an individual readiness assess ment test (/RAT) to evaluate their own preparation for the exercise. This is followed by a group readiness assessment test ("RAT) where the group needs to agree on the correct answer of the same quiz that was just given. Here, the content for the gRAT and exercise is discussed in greater detail in the
MILITARY MEDICINE, Vol. 180, April Supplement 2015
needed fo r
E m bryo lo g y
FIGURE 2. How linking words relate topics and integrate disciplines. Diagram showing how linking words relate topics to tell the reader of how they connect the topics. In addition, this examination shows how one can begin to relate a topic, such as the cell cycle to different disciplines such as Embryology and neoplasia (Pathology).
groups. As students discuss their interpretation of the material and come to a group agreement of what the correct response to the group quiz questions are, they deepen their learning and understanding of the material. Feedback is given by group members in the discussion of the material during the quiz or by the instructor as they move between the groups during the application exercise. In terms of assessment, individual scores are generated for the /RAT. All the group members receive the same score for the gRAT. Typically, the /RAT and gRAT assessments are MCQs. The students then work through an exercise (applica tion) where they typically apply the principles learned in the preparation material to examples or problems to further their understanding of the material. In this innovation, we replaced MCQs with concept map ping; students construct concept maps as the /RAT (individual maps) and gRAT (group maps), and the gRAT and application are combined in one exercise. In this article, we describe how we designed this modified TBL exercise around the use of concept maps and present preliminary results and next steps.
METHODS This innovation occurred during their first module at our medical school, the Fundamentals module (http://www .usuhs.mil/curriculum/pdf/CRNewClassof2018.pdf). In this
65
Using Concept Maps in a Modified Team-Based Learning Exercise
module, 14 individual courses are represented and present the foundations of their courses in this integrated module. The material presented has a specific science theme for each of the 7 weeks of instruction. Students were asked to review module material for their upcoming module final examina tion as their preparation for this modified TBL exercise, as we wanted to use this exercise as a review session, or “put ting it all together” for the Fundamentals module, thus the preparation was to “study for the final examination” of the Fundamentals module.
The Modified TBL Session The students were seated in small groups of 5 to 6 students per group, typical of a classic TBL session. A student was designated as the team leader for each group and he/she was responsible for ensuring the quizzes and group exercises were appropriately carried out and they distribute the /RAT and gRAT directions from the material in a folder on each table. The /RAT was given first to the students. The /RAT instructions were to create an individual concept map using the topic of “inflammation.” Students were instructed to include anything they had learned in the module to the concept of “Inflammation.” Students were given approximately 20 minutes to complete the /RAT (individual concept map). The team leader collected the /RAT papers into the folder. Following the /RAT students proceeded to the »RAT. Team leaders were instructed to distribute the combined yRAT and application activity sheets. These two items (yRAT and appli cation activity) were the same in our exercise; however, they are separate parts of a typical TBL. In this exercise, students were instructed to create a group concept map in which they needed to use 30 concepts pulled from topics instructed in the Fundamentals module and show how they relate to one another. They could use any of the 30 topics as their starting topic for the concept map, such as inflammation, which they were just given for their individual concept map. They were given a large piece of paper, such as from a flip chart, and were told they could add more sheets of paper if needed. Students were also told they could add any additional topics from the module, but at a minimum they needed to use the 30 concepts from the Fundamentals module given to them. Students were given approximately 75 minutes to work. Students were given feedback during this application por tion of the exercise by faculty who rotated around the tables as soon as the group exercise began. Faculty specifically encour aged students to include linking words and cross-links.13 The linking words tell the reader how the student links two con cepts together. For example, the concept inflammation can be divided into acute and chronic inflammation. The linking word between inflammation and acute could be “can be,” so the reader would follow that inflammation “can be” acute, and so forth. Cross-links are links that span between concepts of one arm or branch of the concept map to another arm or branch. This shows a higher level of learning from the student when they realize that concepts link across broader areas. A modified
66
I
© FIGURE 3. Sample Individual Concept Map. Typical concept map from a student working individually given the topic of inflammation and asked to include concepts from all disciplines studied in the Fundamentals module. Concept maps vary greatly between students as they show how each student individually links the concepts together.
example of an individual concept map produced during this exercise using inflammation as the starting concept is given in Figure 3.
Student Grading Grading of /RAT or individual concept map was performed by two graders independently as there is subjectivity to grading. Elements taken into account for grading included the amount of content and accuracy of content included in the concept map, whether students used linking words and cross-links. In our exercise, we wanted the students to get beyond acute and chronic inflammation and include the predominant cell types in each of these types of inflammation, and how inflammation is related to immunity, mediators of inflammation, and so forth to receive full credit for content for this individual quiz. Grading of the group maps was done by a primary reviewer, with a second reviewer reviewing all the concept maps and providing a second opinion for the maps that were between two grades. The two reviewers then jointly discussed any concept maps where the opinion differed in grading, and came to a consensus grade. Group maps were set up a little differently than the individual concept maps as the students had the list of the 30 topics that needed to be included in the group concept map. The list was provided to provide an anchor for student discussion, structure to this new group
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
exercise, and to facilitate evaluation. Thus, to receive full credit for content, all of these 30 items needed to be included in the concept map. Students were encouraged to add addi tional concepts beyond these 30 that were given to them, and the majority of the groups did this as well. Grading of the individual and group concept maps was done on a 2-point scale (pass or fail). This description of an educational inno vation does not include actual data from research participants nor does it involve patient or other sensitive data. PRELIMINARY RESULTS We collected preliminary data on our modified TBL activity. We will begin with discussing grading and then will present our feedback findings. G ra d in g
Individual and group concept maps were evaluated as above for content (knowledge of concepts), use of linking words, and the use of cross-links (knowledge organization and inter relationships of concepts) in the assessment of the concept maps both in the /RAT and gRAT exercises. Quality of both the individual and group maps varied. The group concept maps or gRATS were generally of high quality as students received feedback during the session from faculty as described above and were encouraged to include linking words, cross-links and additional topics if they had not already done so. Additionally, group maps involved student discussion, students had more time to complete the exercise, and for the group activity, they were given a list of 30 concepts to include in their maps. Individual concept maps demonstrated less detail and organization than the group maps, meaning these individual concept maps included less information and did not have as many linking concepts from multiple disciplines that were taught in the Fundamentals module. For example, individual concept maps were often divided into acute and chronic inflammation, and included the basic cell types seen in acute and chronic inflammation, but did not include many other topics from the Fundamentals module. On the other hand, the group concept maps were much more complex concept maps that included more detail and organization compared to the individual concept maps as these maps needed to include the 30 concepts given in the group exercise. To link these 30 concepts, the students had to work together and think broadly about all material presented in the Fundamentals module. The 30 concepts given to the students to be used to construct the group maps were pulled from topics presented by the 11 different courses that were taught in the Fundamen tals module. These courses included basic sciences (Biochem istry, Histology, Embryology, Microbiology, Pharmacology, Immunology, and Pathology) as well as the clinical sciences (Patient Interviewing, Physical Examination, Patient Safety, and Psychology). The group maps, in addition to having more concepts, were of higher quality as they all included
MILITARY MEDICINE, Vol. 180, April Supplement 2015
linking words and many groups had created cross-links that spanned among the different concepts and across traditional disciplines furthering their understanding of the integration of the individual courses and the basic and clinical sciences. A modified example of a typical group concept map from this exercise is shown in Figure 4. F a c u lty a n d S tu d e n t F e e d b a c k
Faculty observed that students were very involved in the group concept map exercise and that it was hard to stop the group discussions at the end of the session. Students used the entire time, which was 75 minutes, to work on the group concept maps. Faculty commented that students were actively engaged in discussing the concepts assigned, and discussing how the various concepts best are linked together. At times, they were able to link the concepts directly, other times, they linked the concepts by adding additional concepts from the Fundamentals module that were not on the list given to them in the instructions. Faculty members who had taught in the Fundamentals module had opportunities to review some or all the student group concept maps. Faculty were surprised to see the variety of topics chosen by the students as the starting point for their group concept maps, and how the students integrated their specific course with other material in the Fundamentals module, both in the basic and clinical sci ences. Faculty who taught in the Fundamentals module who reviewed these group concept maps had a unique glimpse into how the students organized the material presented to them in a unique way and provided an opportunity for these faculty members to self-reflect on how they presented their material in the context of other material in the module. Student feedback has been largely positive. Several stu dents provided positive feedback regarding the value of this exercise, and started to use concept maps regularly as part of their individual learning and study habits. In a few instances, students have commented that using the concept maps has refined their understanding of topics and has significantly helped them achieve higher scores on traditional MCQ exam inations. Students felt that there was sufficient time in the exercise to complete the individual and group concept maps. The next steps for the faculty are to improve the precision of grading, as there is individual variation in how the knowledge is organized and the amount of detail provided in some of the topics in the concept maps. NEXT STEPS Based in part on the preliminary success of this innovation, concept maps are now being used in multiple additional modules during the preclerkship timeframe. We have observed that students who create a less detailed concept map than they had constructed earlier in the curriculum often have poor study habits. As shown in Figure 5, a modi fication of a concept map for the Cardio-Pulmonary-Renal examination that is much more linear (i.e., less branching)
67
Using Concept Maps in a Modified Team-Based Learning Exercise
( T h e C e ll ]
/ \
A u t o im m u n e D is o r d e rs
____ _____ J \
(------------------------------—
can cau se
c o n t a in s \
\
has ----------- \
[ C e llu la r C o m p o n e n ts
[ D N A } r e p lic a te d d u r i / C e ll C y le 1
y
j
\
i
v----------------------'
can be
y
[in h e r ite d
—
q
\ r
can be
,, b e — [ M u ta te d ]
1
/ c a n le a d to
j
f D am aged
/
I
a n g i o g e n e s i s — [ N e o p la s ia j
c a n le a d t o
r e p a ir e d b y
A u t o i m m u n e D is o r d e r s [ Enzym es c a n le a d to
\
f H y p e r s e n tltlv lty
[ is a n
Ig E
s u c h a s — [ A n tib o d ie s )
N Type 1
j
p ro d u c e d by m ake
f B L y m p h o c y te s
[ A d a p tiv e c h a n g e ^
, ty p e
I
/
a c tiv a te d th ro u g h
m a y ln d u c e
[ In f la m m a t io n j
I tr ig g e r s fr o m
I [ In fe c tio n j \ tre a te d b y
[ M e t a b o liz e d
j
* m ust be
y
[ D ru g s j — a re
[E lim in a te d
j
“r
ir e s c r ib e d
- I s r e la te d to - > [ Q u a lity H e a lth C a r e
j
e v a lu a te d b y
rz ~ ~ h ( P a tie n ts ) —
e v a l u a t e d w i t h ------------ >
-----------> I P h y s ic a l E x a m
f P a tie n t S a fte y 1 l
)
FIGURE 4. Sample Group Concept Map. A group concept map excerpt from our exercise where the students were given 30 concepts that needed to be linked together. In this process, students discussed how topics from different courses are integrated and inter-related.
than expected.13 This concept map, when examined at a basic level, looks like “rain” streaming down in a linear fashion and does not show the level of branching or cross-links that we would expect to see in a learner who is continuing to acquire and organize knowledge on a topic. Further, poor
68
performance on a concept mapping exercise appears to corre late with poor performance on future examinations relating to the topic. Thus, we believe, concept maps may be a useful indicator of students who are in academic difficulty and can be used as a starting point to discuss individual learning
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Using Concept Maps in a Modified Team-Based Learning Exercise
t ^ C or Pulm onale
FIGURE 5. Linear Concept Map. Concept map showing a "rain” pattern of linear thinking. This is not the typical branching pattern that is expected in concept maps and does not have cross-links indicated.
habits and help students visualize where their understanding may need to improve. In addition, reviewing the concept map provides a unique lens in assessment by seeing the graphic display of topics of the concept maps and how the students understand how these topics are related and inter-related. As faculty recog nize the value of seeing this type of integrated assessment, they have been willing to add concept maps as part of the faculty-derived assessment at the midterm or end-of-module faculty-derived examinations. Concept maps may also be a means to assess group per formance as group concept maps provided a method for the students to engage each other in topics, work together in a team to discuss how the topics are inter-related, and quiz each other on the topics to review for the examination as the exercise was initially designed as a review session. Concept maps can also be used to evaluate a curricu lum. Concept maps not only engage the students to think interdisciplinary, but also can be reviewed by the faculty to evaluate how the students see course material relating and integrating with other course material. This provides a unique perspective to the curriculum and integration, which are not easily captured in traditional MCQs. We have used the group concept maps to make enhancements to our own curriculum. CONCLUSIONS Modifying a TBL exercise as a basis for practicing how to create concept maps is a novel exercise allowing faculty to assess both knowledge and its organization in students, while students can explicitly see and practice the integration of concepts across the basic and clinical sciences that may not
MILITARY MEDICINE, Vol. 180, April Supplement 2015
be apparent through other types of exercises. The modified TBL format allowed the students the opportunity to first create their own individual concept map, then work together in a team to discuss the concepts being used, how they inter relate, and how to best display this integration of topics in a graphic form in the group concept maps. Using concept maps as a means of TBL assessment provides a means of assessing both student knowledge and their knowledge organization, which is not evident in traditional MCQs typically used in an /RAT or gRAT. Following student concept maps over time may alert the faculty to students who may have learning difficulties with a unique lens that may provide more insight than the limited data provided by a score on a multiple-choice examination. Concept maps created by students show the student perspec tive of how topics are integrated across the basic and clinical sciences and can be used to aide faculty in furthering integra tion of topics across multiple disciplines increasing integra tion in medical education. REFERENCES 1. Cooke M, Irby DM, O’Brien BC: Educating Physicians: A Call for Reform of Medical School and Residency. San Francisco, CA. Jossey Bass, 2010. 2. Michaelsen LK, Watson WE. Black RH: A realistic test of individual versus group consensus decision making. J Appl Psychol 1989; 74(5): 834-9. 3. Millis BJ, Cottell PG: Cooperative Learning for Higher Education Faculty. Phoenix, AZ, Oryx Press, 1998. 4. Michaelsen LK, Sweet M: The essential elements of team-based learning. Chapter 1, In: New Directions for Teaching and Learning, pp 7-27. Edited by M.Wehlburg Catherine. Wiley, 2008. 5. Novak JD. Gowin DB: Learning How to Learn. New York, NY, Cambridge University Press, 1984.
69
Using Concept Maps in a Modified Team-Based Learning Exercise 6. Novak JD: Learning, Creating and Using Knowledge. Concept Maps as Facilitative Tools in Schools and Corporations, London, Erlbaum Associates, 1998. 7. Novak JD: A Theory of Education. Ithaca, New York, NY, Cornell University Press, 1977. 8. Novak JD: Concept maps and Vee diagrams: two metacognitive tools to facilitate meaningful learning. Instr Sci 1990; 19: 1-25. 9. Daley BJ, Conceigao S, Mina L, Altman BA, Baldor M, Brown J: Concept mapping: a strategy to support the development of practice, research and theory within human resource development. Human Resource Dev Rev 2010; 9(4): 357-84.
70
10. Novak JD, Canas AJ: The Theory Underlying Concept Maps and How to Construct Them. Technical Report IHMC CmapTools 2006-01 Rev 01-2008. Pensacola, FL, Florida Institute for Human and Machine Cognition, 2008. 11. Daley BJ, Torre DM: Concept maps in medical education: an analytical literature review. Med Educ 2010; 44(5): 440-8. 12. Daley BJ, Shaw CR, Balistrieri T, Glasenapp K, Piacentine L: Concept maps: a strategy to teach and evaluate critical thinking. J Nurs Educ 1999; 38: 42-7. 13. Torre DM, Duming SJ, Daley BJ: Twelve tips for teaching with concept maps in medical education. Med Teach 2013; 35: 201-8.
MILITARY MEDICINE, Vol. 180, April Supplement 2015
Copyright of Military Medicine is the property of AMSUS and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
