TBL foundations

This innovative approach to student-centered learning is an effective and resource-wise pedagogical tool that can be used in the instruction of a broad range of topics. TBL aligns student learning outcomes with the knowledge and skills required by graduates upon entering the health care workforce.

What principles underpin TBL?

Seven core design elements underpin TBL (Haidet et al, 2012). These have been used as a framework in two systematic reviews summarizing the evidence regarding the extent, design and practice of TBL within medicine (Burgess et al, 2014);  and interprofessional learning in health professions student education (Burgess & McGregor, 2022). The seven core design elements of TBL are:

1. Team formation

Careful attention to how student teams are formed is essential to successful TBL sessions. When assigning students to teams, facilitators should attend to:

• Allocation: Students should be assigned to teams using a transparent process that ensures a diverse mix of students within each team (e.g., consider subject expertise, prior degrees/qualifications, gender). Avoid having students with pre-existing friendships on the same team. 
• Duration: Student teams should stay together in their teams for as long as possible. This enhances team dynamics, trust, and enables diversity of knowledge and skills within the team.
• Size: Teams should consist of 5 to 7 students. This size is large enough to encompass collective intellectual resources, yet small enough to enable individual accountability, teamwork, and interpersonal dynamics.

2. Readiness assurance

By testing individual knowledge, students are encouraged to come to class prepared for the team test and case discussion. Thus class time is used for clinical problem-solving activities, not for covering factual material.  The readiness assurance process makes students accountable for their individual preparation.  Repeated testing during the TBL process provides multiple opportunities for students to engage with the content, benchmark their performance, and recognize gaps in their own knowledge. By comparing their own answers to those of other team members and engaging in team discussion, students build their own learning and contribute to their peers understanding.

3. Immediate feedback

Feedback is provided to students through the IRAT and TRAT processes because answers are discussed immediately after completion of the TRAT, with clarification provided by facilitators.  Immediate feedback is inherent to the TBL process, ensuring that students understand their own level of content knowledge.  Importantly, feedback should also occur during and at the end of the clinical problem-solving activities.  Rather than lecturing, facilitators foster critical thinking by eliciting students’ rationales, identifying gaps in student understanding, and challenging students through follow-up questions. 

4. Clinical problem-solving activities

During the clinical problem-solving activities, teams use their collective knowledge, clinical reasoning, ethical views, skills, and values to solve complex, authentic clinical problems. The use of challenging cases for problem-solving activities encourages participation and increases learning and team development.  Diversity in learners brings various strengths, improving the quality of discussion within teams and student learning outcomes (Parmelee et al., 2012). 

5. Four S’s

To guide the content, structure, and process of the clinical problem-solving phase, Haidet et al (2012) propose that facilitators should follow the four S’s:

• Significant: the problem needs to be significant
• Same: all teams work on the same problem at the same time
• Specific: there is a specific choice in the answer 
• Simultaneous: all teams report their answers simultaneously

Aöthough making a specific choice within the problem-solving activities has traditionally been implemented through the use of multiple-choice questions (MCQs), recent literature suggests that this format may restrict the potential for student discussion and critical thinking (see Burgess et al., 2014. Research suggests that open-ended questions can be effectively used during clinical problem-solving activities (see van Diggele et al., 2026; Burgess et al., 2020). A practical advantage of moving away from MCQs (i.e., specific choice format) within the clinical problem-solving activities is that it averts the difficult task of of writing specific choice questions and answers.

6. Incentive structure

An effective grading system is needed to provide rewards for students' individual work and team contributions during the TBL session.  Grades can be assigned for the IRAT, TRAT, problem-solving activities, and peer review (Parmelee et al., 2012). Another way to assess team performance is to use the clinical problem-solving activities to create a product, such as a mechanistic flow chart.  These products can be compared across teams and assessed in real-time by content expert facilitators. 

7. Peer review

TBL’s peer review process provides students with an incentive to positively contribute to their team’s performance, helping to ensure individual accountability (Haidet et al., 2012; Michaelsen et al., 2014). An additional advantage is that the practice of peer-giving and peer-receiving of feedback encourages students to develop these professional competencies in preparation for entering the workforce, where they will have peer review responsibilities. Contributions that can be assessed by peers include: 

• pre-class preparation; 
• timely attendance to class; 
• constructive participation in team discussions; and 
• valuing and encouraging the contributions of other team members.  

Students should receive explicit instruction on how to provide and receive peer-feedback. 

How is TBL different from other small-group methods?

TBL is one of several active-learning pedagogies frequently used in health professions education. Others include problem-based learning (PBL), case-based learning (CBL) and flipped classroom (FC).  TBL, PBL, CBL and FC are all learner-centered instructional approaches based on the principles of constructivist learning theory.  In all of these pedagogies, learning is based around relevant and authentic clinical problems, activation of existing knowledge, and the application of new knowledge. TBL, PBL and CBL structure active learning in small groups where students are encouraged to apply new knowledge to solve authentic clinical problems through peer learning and small group discussion. However, as summarised in the table below there are also some differences between these instructional approaches.

Further reading

This curated list brings together articles selected by the experts for readers who want to go deeper. The notes below explain what each article contributes and why it may be useful for understanding or applying TBL in health professions education.

Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature.
Haidet P, Levine RE, Parmelee DX, Crow S, Kennedy F, Kelly PA, Perkowski L, Michaelsen L, Richards BF
Acad Med 2012 Mar;87(3):292-9

The authors propose a set of guidelines for standardizing the way in which TBL is reported and critiqued within HPE literature. The paper explains the seven core design elements of the TBL method: team formation, readiness assurance (RA), immediate feedback, clinical problem solving, the four S’s (significant problem, same problem, specific choice, simultaneous reporting), incentive structure, and peer review.

Team-based learning: design, facilitation and participation.
Burgess A, van Diggele C, Roberts C, Mellis C
BMC Med Educ 2020 Dec;20(Suppl 2):461

This paper provides a succinct overview of TBL, summarizing the key components and steps.  It offers guidance on design and facilitation, including team-teaching approaches. Importantly, it outlines both the benefits and challenges of organizing and implementing TBL. 

The educational theory basis of team-based learning.
Hrynchak P, Batty H
Med Teach 2012 ;34(10):796-801

This paper reviews the grounding of TBL on constructivist theory and how it translates into a solid pedagogical approach well suited for health-professions education. 

Reference list

Applying established guidelines to team-based learning programs in medical schools: a systematic review.
Burgess AW, McGregor DM, Mellis CM
Acad Med 2014 Apr;89(4):678-88

Team-based learning: design, facilitation and participation.
Burgess A, van Diggele C, Roberts C, Mellis C
BMC Med Educ 2020 Dec;20(Suppl 2):461

Use of Established Guidelines When Reporting on Interprofessional Team-Based Learning in Health Professions Student Education: A Systematic Review.
Burgess AW, McGregor DM
Acad Med 2022 Jan;97(1):143-151

Perspective: Guidelines for reporting team-based learning activities in the medical and health sciences education literature.
Haidet P, Levine RE, Parmelee DX, Crow S, Kennedy F, Kelly PA, Perkowski L, Michaelsen L, Richards BF
Acad Med 2012 Mar;87(3):292-9

An Introduction to Medical Teaching.
Huggett KN, Jeffries WB, editors
2nd ed. Dordrecht: Springer; 2014

Team-based learning practices and principles in comparison with cooperative learning and problem-based learning.
Michaelsen LK, Davidson N, Major CH
J Excell Coll Teach 2014;25(3-4):57-84

Team-based learning: a practical guide: AMEE guide no. 65.
Parmelee D, Michaelsen LK, Cook S, Hudes PD
Med Teach 2012 ;34(5):e275-87

Engaging Students in Large-Scale Interprofessional Learning Activities: Team-Based Learning (TBL) as a Pedagogical Solution.
van Diggele C, Clarke AJ, Burgess A
Clin Teach 2026 Feb;23(1):e70284