The students achieved the learning outcomes using both instructional strategies in our study, as more than 70% of students answered questions correctly in both modules. However, they attained higher marks with TBL as an instructional strategy (Table1& 2). Students scored higher with TBL as an instructional strategy in both modules, but it was statistically significant in groups 1 and 2 of the emergency module and group 1 of the endocrinology module (Table1). The results are variable in previous studies. In a few studies, TBL was found to be better in achieving outcomes [19, 20]. In another study, students were found to perform better in recall questions with the lecture as an instructional strategy, while, the results were comparable for applying knowledge [21]. A previous study found no significant difference in grades when comparing lectures with TBL if the variable of attendance is constant [22]. A recent study revealed that high achievers performed well in TBL and low achievers in IL even though there is no difference in students’ overall performance using IL and TBL [23]. In another study, TBL was found to be superior in retaining knowledge compared with lecture as an instructional strategy. Students were also more satisfied and more engaged with TBL [24]. Another recent study noted that TBL was significantly superior to lecture in achieving higher grades [25]. One reason for the differences might be the inclusion of traditional lectures in some studies. The level of interaction matters and how an instructional strategy is being used; however, in most of the aforementioned studies, students have a higher level of satisfaction with TBL.

Another interesting parameter of our study was to compare TBL and IL in the learning of clinical reasoning skills. TBL was better in both groups of sixth-year students and group 1 of third-year students, while the difference was not significant in group 2 of third-year students. This finding assumes considerable significance in our context. Even though assessing this skill is not an easy job, clinical reasoning skill is mandatory in medical education curriculum [26]. We used MCQs to assess clinical reasoning. This is a widely used method, among other assessment strategies, to assess clinical reasoning [27]. Feasibility, internal consistency, and students’ awareness and comfort were the factors considered to use this method in our study. According to the literature, TBL is a better strategy to teach clinical reasoning skills [28,29,30]. TBL is superior in achieving higher-order outcomes and solving complex problems, and students prefer TBL over IL, and they found it better to work as a team [31]. So, based on our findings and literature support, we can safely recommend that TBL can be used to learn clinical reasoning skills in the undergraduate medical curriculum.

Students preferred interaction in lectures, among other factors, and they suggested increasing more interaction during lectures. In TBL, they preferred team application, suggesting a preference for involvement in the learning process (Table3). For a long time, it has been emphasized that active learning is better for students in most disciplines [32].

Students prefer TBL over IL in our study, as reflected by their feedback (Table3). TBL, as an instructional strategy, is preferred over other approaches due to many factors. TBL fosters students’ internal motivation, perceived learning, and autonomy, among other variables [33]. Even TBL is found superior to PBL by a cohort of students [34]. It has been observed that TBL enhances knowledge scores when compared to other methodologies, while participants’ reactions are mixed [35]. As promoted by the US Department of Education Fund, TBL has been used in US and international schools for a long time [36]. It has been encouraged to use TBL as an instructional strategy due to different factors, such as the pressure of accreditation bodies to include active learning strategies, feasibility, cost-effectiveness, etc. However, the process of TBL assumes significance for better results that have an advance assignment, iRAT, tRAT, instructor clarification, tAPP, appeal if applicable, and peer feedback. TBL is also important to develop teamwork, communication skills, and collaboration to achieve academic (educational) outcomes [18]. A physician’s skills or competencies are required, as mentioned in the SaudiMEDs framework [11]. Some competencies, for instance, teamwork and communication skills, were also evaluated in the modules by checklist, peer feedback, but these parameters were excluded in this study, so these factors are not part of the discussion.

We propose that it is important to incorporate more active learning strategies, such as TBL, in our curriculum because these strategies help students gain an in-depth understanding of the subjects.

Our study has some strengths. A randomized crossover design was used to compare both strategies, which is why every student was a part of each strategy, IL or TBL, at some stage. Secondly, both preclinical and clinical modules were selected. Both direct, in the form of quizzes, and indirect, evaluations were performed in the form of feedback.

However, our study was not immune to limitations. Firstly, this study is confined to two modules, so it cannot be generalized. The study was conducted in all-male campus somewhat further limiting its generalizability. The study was carried out in a medical college with an integrated modular system, which implies that the results might be different from colleges with a traditional curriculum. However, it can be used in similar contexts. Another issue is with regard to assessment; MCQ was used as an assessment method to assess both the outcomes and clinical reasoning skills. Although this method is supported by literature, and all efforts were made to construct good quality questions, we still view it as a limitation because the assessment of clinical reasoning skills is an onerous task [26]. Although students’ feedback was obtained, in-depth perceptions of students are missing.

Another issue was that the in-class duration of IL was shorter than the TBL duration due to administrative constraints and the context of both strategies. This effect was mitigated by providing additional time to students for self-study in the library under direct supervision.

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