Team based learning pedagogy enhances the education quality: a systematic review and meta-analysis

Abstract

Background

In medical education, Lecture Based Learning (LBL) is the most common way of disseminating information. Team Based Learning (TBL), a new teaching method, is a teacher-guided method that employs teams in a class, showing suitability for medical education. Two teaching methods represent distinct educational approaches, each with its own set of advantages and limitations. In this study, we performed a systemic review on the efficacy of TBL pedagogy in medical education.

Methods

MEDLINE, EMBASE, the Cochrane Library, and Web of Science database were searched through July 2022. Standard mean difference (SMD) and 95% confidence intervals (CIs) were calculated.

Results

The analysis included 33 studies. Our analysis revealed that students utilizing the TBL method exhibited significantly higher pre-( SMD = 0.51, 95%CI 0.11 to 0.92) /post-test (SMD = 0.96, 95%CI 0.70 to 1.22) scores than students with LBL. Students in TBL classes had better development of scores, retention (SMD = 1.03, 95%CI 0.38 to 1.69), engagement (SMD = 2.26, 95%CI 0.23 to 4.29) and higher satisfactory rate (SMD = 1.08, 95%CI 0.87 to 1.29). However, students required more time to independently complete reading materials and preparatory tasks.

Conclusion

Our study indicates the gratifying effectiveness of TBL application in medical education. TBL pedagogy is compatible with the present medical education and should be generalized in more classrooms.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-025-07175-x.

Introduction

Team Based Learning (TBL) was initially introduced in 1970 [1]. It is a teacher-guided small-group learning method that involves students in both individual and group activities [2]. TBL method is an active learning strategy that has gained significant attention in medical education for its ability to enhance student engagement, critical thinking, and knowledge retention [3, 4]. It has since been adopted by many medical schools [5]. TBL consists of three phases: preparation prior to class, readiness assurance progress, and application of course concepts [6]. First, students are provided with educational information, and complete out-of-class study by finishing reading assignments determined by the teachers, mastering the intended learning outcomes. In the second stage, the Individual Readiness Assurance Test (IRAT) and Group Readiness Assurance Test (GRAT) are conducted. These tests evaluate the students’ readiness to apply the knowledge from the reading assignments complete in the first stage. Finally, application exercises are given, which require students to apply the knowledge acquired in the first two phases to solve problems [7, 8].

The TBL method demonstrates greater cost-effectiveness when implemented with a high student-to-faculty ratio [9]. TBL can reduce education costs and increase students’ self-learning capabilities and classroom engagement [10]. Students have shown that students in TBL method achieved significantly higher knowledge scores and retention [11]. However, TBL also have several negative aspects. It can be more challenging to motivate students in TBL, deviations from the core concepts of the course may occur [12], TBL requires more time and energy [13], and students with a weak foundation may experience a greater burden [14].

Lecture Based Learning (LBL) is the most common way of disseminating information in medical education [15]. The main benefit of traditional lecture is that they can be delivered to a large number of students, while the dissemination of knowledge and the classroom environment can be controlled by the teacher [16]. As a passive learning tool, reduced engagement may have a negative impact on students’ attention spans, attendance rates and final exam outcome. At present, several meta-analyses have compared TBL and traditional learning methods in medical education. Gao et al. found that, compared with the traditional pedagogy among nursing students, TBL significantly increased theoretical performance, and professional efficacy but did not affect practical skills [17]. Korayem et al. suggested that TBL enhanced student performance in pharmacy education compared to traditional teaching, although the difference was not statistically significant [18]. These reviews were well-designed, with clear and accurate analyses, and their conclusions are reliable. Present reviews [17–21] focused primarily on single disciplines, such as nursing or pharmacy students, and mainly assessed student performance. We aim to conduct an analysis across various medical education fields, focusing not only on students’ academic performance but also on their participation and satisfaction in the classroom. Therefore, we performed a systematic review of the available literature on the efficacy of TBL pedagogy in medical education compared to LBL. We aimed to uncover the effectiveness and disadvantages of TBL and LBL in medical education.

Methods

Study design

This meta-analysis followed guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis: The PRISMA Statement [22]. The researcher has registered and published a Meta-analysis protocol on International Platform of Registered Systematic Review and Meta-analysis Protocols (INPLASY) (No: INPLASY202510069).

Literature search strategy

The following electronic databases were systematically searched until July 2022: MEDLINE, EMBASE, the Cochrane Library, and Web of Science.

The following index words were used: Team Based Learning or TBL, traditional learning or Lecture Based Learning or control or traditional lecture, medical education or medicine. Relevant reviews and meta-analyses comparing the effect and efficacy of TBL and LBL in medical education were also examined manually to identify additional eligible studies (Supplement 1).

Inclusion criteria

Include criteria: (1) the trials should clearly describe 2 interventions (TBL and LBL); (2) the reported data should include at least one primary outcome, with or without secondary outcomes; (3) the study should provide detailed quantitative results for both the TBL and LBL groups; (4) data should be available, extractable, and usable for pooled analysis. To ensure global accessibility of all studies, only those written in English were included.

Types of outcome measures

The primary outcome evaluated in the meta-analysis was final examination scores. The secondary outcome was the advantages of both teaching methods.

Data extraction and quality assessment

Two reviewers (Z.B.X and Y.F.Z) independently screened potentially eligible studies and independently extracted the following data: authors, publication year, study design, interventions, and outcomes. Two reviewers independently extract data from the studies. After the independent extraction, the reviewers compare their results. If discrepancies are found, the reviewers resolve the differences through discussion. If disagreements between the reviewers cannot be resolved through discussion, a third reviewer (X.Y.L), is typically brought in to assist in resolving the dispute. In this study, we used “RoB 2: A revised Cochrane risk-of-bias tool for randomized trials” as quality assessment tool, and summary quality assessment result was supplied as Supplement Table.

Statistical analysis

In this study, all statistical calculations were performed using Stata 12.0 (Stata Corp, College Station, TX, USA). Standard mean difference (SMD) with 95% confidence interval (CIs) was calculated for continuous variance. Heterogeneity was assessed by calculating I². When I² was less than 50%, we used a fixed-effects model. While I² was more than 50%, a random-effects model was used to judge the heterogeneity. χ² test was used to assess homogeneity among all enrolled trials with the significance threshold set at P>0.1. Sensitivity analysis was performed by excluding each study individually to reassess the quality and consistency of the results. We had also performed subgroup analysis to explore the diversity among different studies and source of heterogeneity. Publication bias was assessed using Egger’s test and funnel plots [23, 24] in Stata 12.0.

Results

Characteristics of the included studies

After carefully reading the abstract and the full text of the literatures (the literature retrieval process is shown in Fig. 1), we enrolled 33 studies in this study [4, 12–14, 25–53]. Among these, 9 studies [13, 27, 34, 43, 46, 50–53] were randomized studies, while the design of the remaining 24 studies [4, 12, 14, 25, 26, 28–33, 35–42, 44, 45, 47–49] was not randomized. The characteristics of the included studies are shown in Table 1.

Fig. 1.

Selection process for trials

Table 1.

Characteristics of the included studies

Study ID	Country	Study design	Age	Participant (TBL/Control)	Curricula	Result
Ulfa et al. 2021 [14]	Japan	RCT	Mean age: 19.19 (TBL) /19.15 (Control)	Second-year diploma level midwifery students (62/53)	Postpartum hemorrhage (PPH)	The mean clinical reasoning on PPH scores (post-test and 2 weeks post-test) and Classroom Engagement Survey (CES) were significantly higher in the TBL students.
Tan et al. 2011 [17]	Singapore	Modified crossover study	Mean age: 21.4 (TBL) /21.4 (Control)	Third-year medical undergraduates (49/49)	Neurological emergencies and neurological localization.	TBL showed greater improvement in knowledge scores, with continued improvement up to 48 h later. This effect is larger in academically weaker students.
Thrall et al. 2016 [47]	US	RCT	N/A	People attending daylong workshop on treating attention-deficit hyperactivity disorder (56/59). Overall, 42% of all randomized participants completed the remote post-test (24/24).	Attention-deficit hyperactivity disorder	At the end of the intervention day and after 2 months, knowledge test scores were not meaningfully different between 2 groups.
Bleske et al. 2018 [28]	US	Randomized crossover study	N/A	Totally,28 s year professional students and 2 third year professional students. A total of 16/30 students took the post-course assessment (8/8).	An advanced elective therapeutics course	The results showed no significant difference in long-term assessment scores between TBL and lecture formats. There was a significant and similar decline in short-term gains for TBL in assessment scores.
Bleske et al. 2016 [16]	US	Randomized crossover study	N/A	Totally,28 s year professional students and 2 third year professional students.	An elective therapeutics course	Learning outcomes and student confidence in performing higher-order tasks were significantly higher in TBL group.
Zeng et al. 2021 [53]	China	Randomized study	Mean age: 22.9 (TBL) /23.0 (Control)	Fifth-grade clinical undergraduates (26/26)	Dermatology and venereology course	TBL model is better in enriching students’ professional knowledge and cultivating their comprehensive ability. It can effectively promote educational quality, improve students’ learning effects, and enhance their satisfaction.
Zeng et al. 2017 [54]	China	Randomized controlled trail	Mean age: 20.02 (TBL) /19.96 (Control)	Third-year medical undergraduates (55/56)	Symptomatology of dyspnea and palpitation	TBL in symptomatology approach was highly accepted by students in the improvement of interest and self-directed learning and resulted in an increase in knowledge acquirements, which significantly improved short-term test scores.
Taglieri et al. 2017 [46]	US	Cohort study	Mean age: 24.0 (TBL) /24.1 (Control)	Immediately prior to graduation, both cohorts of students were invited (222/147)	Over-the-Counter Drugs/Self-Care Products course	Although TBL is thought to improve student engagement and mastery of material, after an initial implementation of TBL, knowledge retention in the long term appears to be lower than lecture-based learning.
Rezende et al. 2020 [43]	Brazil	Quasi-experimental study	Mean age: 19.3 (TBL1) /19.7 (TBL2) /20.8 (Control)	First-year medical students (157/76)	Neuroanatomy	TBL seems to be a promising strategy to improve the teaching of neuroanatomy in medical schools. It fosters group discussions and increases satisfaction and the perception of integration between clinical and basic sciences.
Xue et al. 2021 [50]	China	Quasi-experimental study	N/A	Five-year nursing students (48/27)	Nursing	TBL significantly improved students’ self-directed learning and classroom engagement. The scores for 6 of 9 items in the Student Evaluation of Teaching and Units (SETU) were significantly higher in the TBL group
Harakuni et al. 2015 [36]	India	Non-randomized Control Study	Age range: 18–20 years	Second term students (49/39)	Systemic bacteriology	The TBL group outperformed the self‑study group on the post‑test. Female students performed better than males on the pre‑test, scoring higher within both groups. Male students in the TBL group performed significantly better on the post‑test.
Kim et al. 2020 [38]	Korea	Quasi-experimental quantitative design	23–25 years old: 21, 58.3% (TBL) / 20, 69% (control)	Early-stage nurses in intensive care units (36/29)	Electrocardiography (EKG) training program	TBL could not enhance the knowledge of electrocardiography and reading ability of bedside. TBL was more effective in improving nurses’ reading ability of the 12-lead EKG.
Gong et al. 2022 [35]	China	Randomized study	Mean age: 22.53 (TBL) /22.29 (Control)	Medical students (15/15)	Pediatric clinical practice	Application of TBL in bedside teaching not only enhanced clinical practice skills among medical students but also improved their clinical reasoning and counseling skills.
Lee et al. 2018 [39]	Korea	A quasi-experimental study (95/88)	Mean age: 23.57 (TBL) /23.48 (Control)	Senior nursing students (95/88)	Adult health nursing course	TBL group had significantly better clinical competence skills, communication competence, and self-leadership.
Yang et al. 2014 [52]	China	Randomized study.	Mean age: 22.0 (TBL) /21.6 (Control)	First year medicine school student (43/43)	Anatomy	TBL could improve not only the test scores of the students, but also their study enthusiasm, initiative learning ability, communication ability, and team awareness.
Echeto et al. 2014 [31]	US	An experimental study	N/A	Senior dental students (78/79)	A removable partial denture (RPD) course	Students who learned RPD with TBL scored higher on the examination and the TBL students’ proportion of passing grades was statistically significantly higher.
Lein et al. 2017 [40]	US	A retrospective study	Basic skill: 23 (TBL) /24 (Control) (mean age); Cardiopulmonary: 24 (TBL) /23 (Control) (mean age)	Physical therapy curriculum student	Basic skills and cardiopulmonary	For both courses, the mean exam score was significantly higher in the TBL group: basic skills course and cardiopulmonary course.
Eguchi et al. 2020 [32]	Japan	Cohort study	N/A	First-year medical students (122/122)	Glucose metabolism	TBL was more effective than traditional lectures in supporting knowledge retention.
Ghorbani et al. 2014 [34]	Iran	Cohort study	N/A	First-year physical therapy students (30/30)	Anatomy	Students had a higher satisfaction rate with the TBL. Additionally, higher scores were obtained in the TBL group.
Das et al. 2019 [30]	India	An interventional comparative study	N/A	Professional Bachelor of Medicine and Bachelor of Surgery students (48/46)	Clinical Biochemistry	No significant difference between the two groups in problem solving skills. High achievers performed better after TBL session, while the low achievers were more benefited by traditional lecture method. The female students showed better academic performance after TBL in comparison to male students.
Chen et al. 2017 [29]	China	N/A	N/A	Foreign Africa students and Chinses graduates (14/7)	Hematology	The practice test scores of TBL were significantly higher. The TBL group had increased motivation to prepare before class, an engaged classroom atmosphere, and an improvement in their understanding of difficult topics. Chinese postgraduates also benefited from this setting, as they found that this interaction improved their communication in the English language.
Mody et al. 2012 [7]	US	Cohort study	N/A	Third year medical students (69/61)	Obstetrics and gynecology	The TBL group reported higher scores. Both groups gained significant amount of knowledge. The change in scores was not significantly different between the groups.
Sakamoto et al. 2019 [44]	Brazil	Randomized, controlled, parallel, two-arm, non-blinded clinical trial	Mean age: 21.8 (TBL) /20.7 (Control)	Ungraduated student (14/11)	Nursing	Students’ apprehension of knowledge in the TBL group was significantly higher by considering the pre-test results. After 30 days, there was no significant difference between groups.
Salih et al. 2021 [45]	Sudan	Cohort study	N/A	Fourth-year and sixth-year medical students (378/378)	Pediatrics	Students’ performance using TBL was superior, irrespective of students’ gender, noticeable among senior students.
Yan et al. 2018 [51]	China	Randomized study	Mean age: 19 (TBL) /19 (Control)	First year college student (98/99)	Anatomy	The students in TBL group had higher examination scores. The ratios of students with excellent and good scores were markedly increased in the TBL group. The students in TBL group significantly achieved some improvements in mutual communication ability, generalization capacity, cooperative ability cultivation, knowledge extension, and enthusiasm mobilization.
Wiener et al. 2009 [49]	Austria	Parallel study	17–20 years old: 72%; 21–25 years old: 23%; >25 years old: 5%	Self-selected student (386/1030)	Intensive course	Using the final exam as an outcome measure, TBL group student had higher. They also had a 16.5% higher score in the remaining 5 non-TBL blocks of the year.
Alamoudi et al. 2021 [26]	Saudi Arabia	A quasi-experimental non-equivalent comparison group design study	N/A	TBL: second year clinical nutrition students (n = 33); control: second year nursing students (n = 70).	Clinical biochemistry course and nursing	In the post-course exam, clinical nutrition students (TBL) scored higher.
Rajati et al. 2018 [15]	Iran	A quasi-experimental study	Mean age: 20.37 (TBL) /24.43 (Control)	Public health students (23/14)	Health education	The mean of final examination score in TBL group was significantly higher.
Alimoglu et al. 2017 [27]	Turkey	A prospective controlled follow-up study	Mean age: 24.3 (TBL) /24.0 (Control)	Three-year student (194/174).	Neurology	We found no difference between groups regarding end-of-clerkship exam scores. The mean knowledge retention test score of the TBL group was significantly higher.
Faezi et al. 2017 [33]	Iran	A quasi-experimental design	Mean age: 22	Third-year medical students	Rheumatology	The CES scores indicated a high level of engagement in TBL. The student scores obtained from the short answer questions showed that over time the students’ scores had declined significantly less for the TBL sessions.
Maslakpak et al. 2015 [37]	Iran	A quasi-experimental study	Mean age: 23.22 (TBL) /22.5 (Control)	Third grade nursing students (30/32)	Nervous system	Using TBL method compared to the traditional lecture approach resulted in more improvement and stability in the knowledge of nursing students in the nervous system examination skills.
Levine et al. 2004 [41]	US	N/A	N/A	Third-year students (281/71)	Psychiatry core clerkship	Incorporating team learning into the psychiatry clerkship was associated with improved student performance and increased student engagement and satisfaction.

Abbreviation: CES: Classroom Engagement Survey; EKG: Electrocardiography; LBL: lecture-based learning; PPH: Postpartum hemorrhage; RCT: Randomized controlled trail; RPD: Removable partial denture; SETU: Student Evaluation of Teaching and Units; TBL: team-based learning

Outcomes

Final scores in students with TBL or LBL methods

Totally, 28 studies [4, 12–14, 25–28, 30–37, 40, 41, 43–48, 50–53] reported the final scores in students with TBL or LBL method. We found that students with TBL method had significantly higher post-test scores than students with LBL (SMD = 0.96, 95%CI 0.70 to 1.22, I² = 93.4%, random-effects model) (Fig. 2A). This trend was consistent in both randomized and non-randomized studies (Fig. 2B).

Fig. 2.

The final scores and pre-test scores in students with TBL or LBL methods. A. Pooled results of final scores in students with TBL or LBL methods; B. Study with/without randomization of pooled results of final scores in students with TBL or LBL methods; C. Pooled results of pre-test scores in students with TBL or LBL methods

Pre-test score in students with TBL or LBL methods

A total of 13 studies [4, 14, 25, 28, 33, 35–37, 41, 43, 46, 47, 51] reported the pre-test scores in students with TBL or LBL method, the results showed that students with TBL method demonstrated significantly higher pre-test scores compared to those using LBL after team-based preparing lessons (SMD = 0.51, 95%CI 0.11 to 0.92, I² = 89.3%, random-effects model) (Fig. 2C). This indicated that students using the TBL method could gain more knowledge and had better performance after long-term team-based preparation.

Benefits of TBL method

Score development

The TBL method improved the final scores of all enrolled students, especially among high-achieving students. Two studies [29, 50] found a significant increase in the proportion of high achievers in the TBL group, while the proportion of students who barely passed decreased [50]. Tan et al. found that academically weaker students, identified by lower examination scores, showed greater score increases with TBL [14]. The number of students with better performance was also increased markedly in TBL group [46]. Two studies observed a greater improvement in post-class scores among students in the TBL group compared to the LBL group [36, 47]. Additionally, three studies found that TBL group showed a smaller decrease in scores compared to the LBL group over time [32, 47, 48].

Engagement

Compared to students in the LBL group, pooled results from three studies [40, 47, 49] showed that students in the TBL group exhibited a significantly higher level of engagement (SMD = 2.26, 95%CI 0.23 to 4.29, I² = 98.2%, random-effects model) (Fig. 3A).

Fig. 3.

The benefits in students with TBL methods. A. Pooled results of engagement in students with TBL or LBL methods; B. Pooled results of retention in students with TBL or LBL methods; C. Pooled results of satisfaction in students with TBL or LBL methods; D. Pooled results of Chinese and other countries’ students with TBL or LBL methods

Knowledge retention

Four studies [13, 25–27] indicated that the mean test scores of knowledge retention (the process by which information is stored, and later retrieved from memory) were significantly higher in the TBL group than in the LBL group (SMD = 1.03, 95%CI 0.38 to 1.69, I² = 86.7%, random-effects model) (Fig. 3B).

Satisfactory

Numerous studies reported that students expressed satisfaction with TBL lessons and would like to repeat the experience [4, 12, 13, 25, 26, 30, 34, 40, 42, 49–52]. Pooled results [26, 34] also indicated that the level of satisfaction among students in the TBL group was significantly higher (SMD = 1.08, 95%CI 0.87 to 1.29, I² = 0.0%, fix-effects model) (Fig. 3C).

Other benefits

The TBL method increased motivation [36, 42, 48, 52] and created a more engaged class atmosphere [12, 28, 47, 50]. It also enhanced comprehension [26, 28, 35, 52], promoted active learning [34, 35, 49, 52], improved counseling and problem-solving skills [4, 12, 34], and reinforced self-leadership [38, 49, 52] and teamwork abilities [34, 38, 40, 50, 52].

Defects of TBL method

Previous research determined that the most common defect of TBL method wasthe increased preparation time required by students (134 vs. 19 mins) compared to those in the LBL group [13, 53]. Additionally, while high achievers in the TBL group performed better in problem-solving skills assessments compared to their counterparts in the traditional LBL group, low achievers in the TBL group had significantly lower scores in problem-solving exercises compared to those in the LBL group [29]. The TBL class required more engagement, but motivating students might be challenging. The lack of centralization could complicate the learning process and lead to deviations from the core concepts of the course [12].

For Chinese students, the TBL method was a novel teaching approach used in only a few classes, while most Chinese classes still relied on the LBL method. In our analysis, 6 enrolled studies [28, 34, 50–53] focused on Chinese students, while the other 20 studies [4, 12–14, 25–27, 30–33, 35–37, 40, 43–48] focused on Western country students. We conducted subgroup analysis to examine the differences between Chinese and Western students. Results showed that both groups benefited from the TBL class, with Chinese students (SMD = 0.58, 95%CI 0.23 to 0.93, I² = 67.0%, random-effects model) and Western students (SMD = 1.07, 95%CI 0.76 to 1.38, I² = 94.7%, random-effects model) showing significant improvements. Western students appeared to benefit more from the TBL method compared to Chinese students (Fig. 3D).

Sensitivity analysis and publication bias

To evaluate the robustness of meta-analysis results, we repeated all meta-analysis using different models (fixed- or random-effects). The result was consistent across all models, indicating the reliability of our findings.

Funnel plots were generated and analyzed using Egger’s tests to assess the risk of publication bias across all studies. The funnel plots appeared symmetrical, suggesting the absence of publication bias, which was confirmed by Egger’s test (t = 1.70, P = 0.101) (Fig. 4).

Fig. 4.

Funnel plots

Discussion

LBL and TBL methods represent two distinct educational approaches, each with unique advantages and challenges. In this study, we performed a systemic review of the efficacy of TBL pedagogy in medical education. The TBL method can benefit medical students in multiple ways.

The application of TBL in medical education has many advantages, though it also presents some challenges. It emphasizes student-centered learning, promoting student engagement, discussion-based learning, and peer-to-peer instruction through teamwork [54]. TBL not only focuses on cultivating students’ clinical skills but also learning foundational knowledge, achieving a balance between basic theory and clinical skill training [26]. Moreover, TBL enhances students’ abilities to analyze and solve problems, as well as their teamwork and interpersonal skills through collaboration [26]. The application of TBL in medical education can improve students’ self-directed inquiry, collaborative learning, language expression, and communication skills through small group discussions in large classes. It is suitable for medical students at any stage, particularly in group teaching involving a large number of students, which aligns with the educational context in China [34, 55].

However, TBL also faces some challenges in the implementation process, including its time-consuming nature of students, high requirements for students’ qualities and abilities, and the demands on faculty and teaching conditions [56]. To effectively implement TBL, teachers need to prepare in advance, including designing teaching units, preparing outlines for pre-study, test questions, and application exercises, while also reasonably grouping and designing grading assignments. In recent years, online teaching has become a trend, and TBL has also been tried in the practice of online medical education [57]. Teachers can carry out pre-class preparation, in-class testing, in-class discussion, and teaching effectiveness evaluation through online platforms to adapt to the online teaching environment.

In addition, TBL, combining TBL with modern educational methods can further improve teaching effectiveness. The integration of TBL with other teaching methods (such as Problem-Based Learning, Case-Based Learning, etc.) can fully leverage the advantages of different teaching methods to achieve better teaching results [58]. Through the formulation of questions, the construction of situations, the task-driven guidance for autonomous learning, and the analysis and discussion of case materials, teachers can build a comprehensive curriculum knowledge system. This integrated teaching method has significant advantages in improving students’ abilities to collect and apply information and materials, independent thinking skills, and the effectiveness of team cooperation in task groups. In a particular implementation, TBL can be integrated with LBL, using LBL’s teaching resources and advantages, to improve students’ application and understanding of knowledge through TBL’s teamwork and discussion [51]. In addition, TBL can be combined with modern educational technologies, such as the flipped classroom, mobile learning applications, etc [59]. It has been reported that flipped classroom combined with TBL enhances students’ academic achievements and garners higher satisfaction rates among participants compared to traditional methods, positioning it as a promising pedagogical model [60]. Moreover, adapting TBL for online and hybrid teaching environments is an emerging trend. The online hybrid environment can break through the spatial and temporal limitations of traditional classroom education. It can facilitate the internationalization of education, foster enhanced international exchanges and cooperation, enable the sharing of educational resources, and help cultivate international talents [61, 62]. Researchers have found that a hybrid online TBL program significantly increases participants’ familiarity, attitude, confidence and satisfaction, which is a feasible and valid approach [63].

In our analysis, we found that students with TBL had significantly higher pre- and post-test scores than those with LBL. Students in TBL classes showed better score development, retention, engagement and higher satisfactory rates. However, students need more time to independently complete reading materials and preparatory tasks. To address this issue, teachers can collaborate and share TBL resources with their colleagues. By pooling efforts, they can reduce the individual workloads and create a library of TBL materials that can be reused and adapted for different courses. For students, clear guidelines and expectations should be set regarding the pre-class preparation, and providing concise and focused reading materials can help them manage their time more effectively. All students rely on each other to complete tasks together. The “free-rider” phenomenon in teams may affect learning outcomes, which is sensitive to the internal dynamics of the team as well as the varying abilities of its members [12]. Implementing peer assessment and individual accountability measures can help mitigate the free-rider phenomenon. Students can rate each other’s contributions to group work, and these ratings can be factored into their individual grades. Additionally, assigning specific roles and responsibilities to each group member can ensure that everyone has a clear task to fulfill, promoting active participation and reducing the likelihood of free-riding.

The Western education system, particularly that of the United States, is the birthplace of TBL, which emphasizes teamwork and student-centered learning. It has been widely applied in higher education institutions across developed countries [64]. The differences between Chinese and Western education models also reflect different cultural values and educational concepts [28]. Western education places more emphasis on individualism, innovation, and the cultivation of critical thinking, while Chinese education traditionally focuses more on collectivism, respect for authority, and mastery of basic knowledge. With the advancement of globalization and the exchange of educational concepts, Chinese and Western education models are gradually learning from and integrating with each other. Many studies [28, 49–52] and our results show that TBL methods have already been successfully used in Chinese classroom, achieving great results. However, there is still a gap in TBL experience compared with Western countries. The differences between Chinese and Western TBL and LBL teaching models reflect not only the teaching methods themselves but also different educational goals.

Globally, TBL in medical education is an important area of study. TBL is not only underutilized in Chinese education system but also represents an alternative teaching model to LBL worldwide. Research indicates that the application of TBL in global medical education is on the rise, particularly in countries like the US [65], Canada [66], Australia [67], and some Asian nations, including Singapore [68]. The adoption of TBL worldwide reflects a demand for more interactive and engaging learning methods [69].

To effectively implement strategies in a TBL class, we would like to establish a dedicated TBL teaching team, which includes experienced TBL teachers and new teachers who are interested in TBL [70]. We will select suitable course content for TBL teaching based on teaching objectives and student characteristics. Systematic TBL training will be provided for teachers, covering aspects such as teaching philosophy, methods and skills, and assessment feedback. Students will be reasonably assigned to different groups, ensuring that each group has a certain diversity in learning abilities, interests, and other aspects. Diversified assessment methods will be used, including self-assessment by students, peer assessment within groups, and teacher evaluation [71]. During the teaching process, we aim to create a positive, open, and inclusive learning atmosphere. Based on students’ feedback and learning outcomes, we will flexibly adjust TBL teaching strategies [72].

Our systematic review had several limitations. First, some of the included trials were non-randomized studies, which could introduce some bias. We conducted sensitivity analysis and publication bias analysis and our findings indicated no obvious bias. Additionally, we repeated all meta-analyses using other types of models (fixed-effect and random-effect), conducted subgroup analyses, and performed quality assessments to detect potential biases between randomized and non-randomized studies. We concluded that our results were reliable. Second, not all studies presented the same outcome. Thus, we performed subgroup analysis, and the outcome was reliable. Third, some studies had small sample sizes, which might introduce bias. Therefore, further studies with well-designed, large sample sizes are needed. Fourth, we only enrolled English-language literature in this study to enable a comprehensive analysis of the data by researchers worldwide. However, the exclusion of non-English literature may lead to publication bias, potentially affecting the research outcomes. We recognize this as a limitation. We hope that in the future, more well-designed, large-sample randomized controlled trials can be incorporated into the analysis to further enhance the quality of this meta-analysis.

Conclusion

The results of our study indicate the gratifying effectiveness of TBL application in medical education worldwide. TBL not only enhances the theoretical scores of medical students, but also enables them to benefit from and enjoy the classes. To comprehensively evaluate the effectiveness of TBL pedagogy, there is a need for more global, high-quality studies and more standardized evaluation methods in the future. Overall, TBL pedagogy is compatible with the current medical education and should be generalized in more classrooms.

Electronic supplementary material

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Author contributions

Conceived and designed the experiments: Z.B.X. and Y.F.Z. Performed the experiments: Z.B.X. X.Y.L. and Y.F.Z. Analyzed the data: Z.B.X., X.Y.C., and Y.F.Z. Contributed reagents/materials/analysis tools: Z.B.X. X.Y.L. and Y.F.Z… Wrote the paper: Z.B.X., X.Y.C., X.Y.L. and Y.F.Z.

Funding

This work was supported by grants from National Natural Science Foundation of China (No. 82271151, Z.B.X. and No. 82472554, Y.F.Z.), Shanghai ChenGuang Program (No. 21CGA14, Z.B.X.), the Fund for Excellent Young Scholars of Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine (No. JYYQ006, Y.F.Z.), and Project of Shanghai Shenkang Hospital Development Center (SHDC12023104, X.Y.L.).

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable reques.

Declarations

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.