ORIGINAL�ARTICLE ABSTRACT Objective: To identify low performers by utilizing individual readiness assurance test (i-RAT) scores in first year MBBS students using Team-based learning (TBL) strategy. Study Design: Cross sectional observational study th Place and Duration of Study: Study was conducted in Federal Medical College Islamabad from 10 January to st 31 March 2022. st Materials and Methods: TBL were introduced in 1 year MBBS. Six TBL activities were practiced by Anatomy Department during the 12-week respiratory and CVS course program. Premedical examination scores, first week individual readiness assurance scores and average i-RAT scores of 6 weeks were gathered. Mean and standard deviation were calculated. Difference in the first week i-RAT scores of three groups based on their premedical examination scores i.e., upper percentile group (A), middle percentile group (B) and lower percentile group (C). Each group comprised of 37 students, was calculated using One Way ANOVA Method. Pearson correlation coefficient (r) was used to access strength and direction of linear association between premedical examination scores and i-RAT scores. The data was analyzed in the statistical package for social sciences (SPSS) version 21 for analysis. Results: High scorers in premedical examination (Group A) showed lowest scores in first week iRAT (i-RAT 1) and Average i-RAT when compared with group B and C with significant p value < 0.05. Significant increase was seen in progressive i-RAT scores in all 3 groups. Negative linear association (r= -0.2) was found between premedical examination scores and i-RAT 1 scores. A strong positive linear association with r= 0.54 was found between first i-RAT and average i-RAT scores. st Conclusion: High achievers in premedical examinations struggled the most in 1 year of medicine. Key Words: Individual Reassurance Test , MBBS, Premedical Scores, Team Based Learning. exceptional scores. Admission to medical college is extremely competitive. Medical studies are associated with chronic and high stress, and evidence has shown that such stress is linked to worse performance, intentions to quit, and elevated 2 depression. Literature has given the evidence that previous academic performance is used as a predictor for future performance in studies of selected students in a medical college though relation of antecedent scores with future performance in medical school years need to be 3 explored. Studies have shown that pretest identifies low performers that might need extra support in learning and once the students at risk are identified educational intervention can help support such 4 students. For this purpose to identify low st performers in 1 academic year of medicine with high premedical scores i-RAT is used in this study while conducting TBL exercises. Introduction Study of medicine is a challenging and tortuous course. It is declared as one of the lengthiest and 1 stressful academic programs. Once entering MBBS, students require knowledge and skill to gain marks that will be sufficient for them to become good doctors in future. Students are selected on merit in st 1 year MBBS but at the end of year show poor performance irrespective of their premedical Utility of iRat as a Tool to Identify Low Academic Performers in 1st Year MBBS with High Scores in Pre-Medical Examination Sana Malik, Atteaya Zaman, Saima Saleem, Saima Mumtaz Khatak, Anbreen Aziz, Madiha Imran Correspondence: Dr. Sana Malik Department of Anatomy Federal Medical College, Islamabad E-mail: sanamalik1211@gmail.com 1,3,4 2 Department of Anatomy/Medical Education Federal Medical College, Islamabad 5 Department of Dentistry Army Medical College, Rawalpindi 6 Department of Anatomy Watim Medical and Dental College, Rawat Received: September 16, 2022; Revised: May 30, 2023 Accepted: June 03, 2023 JIIMC 2023 Vol. 18, No. 2 139 Individual Readiness Assurance Test (i-RAT) https://doi.org/10.57234/jiimc.june23.1534 TBL is one of the popular and effective strategy used 5 in different educational systems. Many medical collages have been using this strategy as primary 6 mode of learning in undergraduate medical setup. The benefits of TBL have been documented in literature many times stating that learning among students increases by active engagement in 7 teamwork and practical skill. Medical curriculum can be strengthened by implementing this instructional approach format, in earlier phases of the first year program where the focus is on basic science, leading to clinical importance as students 8 move towards clinical years. Team based learning exercise for implementation is divided into three phases; preparatory phase; where students study before they come to class, readiness assurance test; where students take both individual a n d te a m a s s u ra n c e te st to a s s e s s t h e i r understanding of pre-class material and application phases, where students apply learnt knowledge. In last phase students work as a team to share and 9, 10 improve learning. Individual readiness assurance test (i-RAT) helps to assess understanding of desired topic from pre class study directions and individual preparation. Team readiness assurance test (t-RAT) gives student an opportunity to get immediate feedback on assessment and team learning. The activity center around students being engaged in groups to solve 11 problem related to topic of concern. i-RAT scores can be used to identify struggling 12 students. Single TBL exercise exposure of first year students of medicine were helpful in identifying top 1 3 performers and struggling ones. Individual readiness assurance test has significant value as literature suggests that it helps to pin down students that might not perform well in academic years of MBBS. TBL programs result in improvement in results of final examination of students interpreting that academically underperforming students are more 7 assisted by team bases learning methodology. Research has been conducted previously to determine factors like personality, IQ, peer and family pressure contributing to be responsible for st low performance in students of 1 year medical 14 college. Less evidence is available how to identify these low performers especially those with high premedical examination scores. TBL activities help in tracking down students at peril to show low academic results. Such students require early interventions to strengthen their performance and educational experience. TBL methodology can be used as a tool for early screening out of students that might perform below par in first year of MBBS irrespective of being high marks achievers in premedical examination. The purpose of carrying out this research project was to utilize an active learning strategy to identify low performers in medical school by utilizing iRAT scores in first year CVS and Respiratory Anatomy Module. Materials and Methods It was a cross sectional observational study with the duration of 12 weeks. Study was conducted for st students of 1 year MBBS (Session 2021) of Federal Medical College Islamabad. Whole class of One hundred and eleven students participated using nonprobability convenient sampling technique. Written consent was collected by all students before start of study. After ethical approval of FMTI ethical review board t h ( 1 5 N o v e m b e r 2 0 2 1 l e t t e r n u m b e r ECPIMS/02/16).Whole class was included with their consent. The Team based learning activity was st introduced in 1 academic session in CVS and Respiratory modules of 6-week duration each. Six TBL activities were practiced by anatomy department during the course program which covered most of the taught anatomy content of the course. Each TBL activity was conducted as a large group discussion engaging whole class at the beginning of week 2,4,6 ,8, 10 and 12. Data was collected for 3 groups of students based on their premedical examination scores i.e., upper percentile group (A), middle percentile group (B) and lower percentile group (C). Each group comprised of 37 students. Following scores were gathered. 1. Premedical examination scores 2. Individual readiness assurance scores 3. Average i-RAT scores of 6 weeks The premedical scores were obtained from college administration listed on basis of merit, i-RAT scores were maintained for each bi- weekly activity and documented on excel sheet and average i-RAT was calculated at the end of 12 week by calculating average of i-RAT scores obtained in six TBL activities. Validity and reliability of the test was ensured as per JIIMC 2023 Vol. 18, No. 2 140 Individual Readiness Assurance Test (i-RAT) https://doi.org/10.57234/jiimc.june23.1534 institutional policy. Mean and standard division of first week iRAT scores and average iRAT scores in 6 TBL activities were calculated for the 3 groups as mentioned in methodology. Difference in the first week i-RAT scores of three groups was calculated using One Way ANOVA Method. Pearson correlation coefficient (r) was used to access strength and direction of linear association between premedical examination scores and i-RAT scores. The data was analyzed in the statistical package for social sciences (SPSS) version 21 for analysis. Result Group A showed lowest scores in first week i-RAT (i- RAT 1) and Average i-RAT when compared with group B and C with significant p value< 0.05 indicating that the high achievers in premedical examinations st struggled the most in 1 year of medical studies as briefed in table I. association help fulfill the objective of identifying low performers in medical school by utilizing i-RAT scores. A strong positive linear association with Pearson coefficient r= 0.54 and significant p value of 0.01 was found between first i-RAT scores and a v e r a g e i - R AT s c o r e s s h o w i n g p e r s i s t e n t improvement. Discussion In early phase of the TBL activity i-RAT assesses students independent learning ability to learning 15 materials shared before class . We found that consistent improvement in weekly i-RAT in students performing in middle and lower percentile as compared to upper percentile students. Studies have documented that premedical scores are high predictors of good academic performance but contradictory evidence is also available in literature that shows no correlation between entrance test 16 examination scores and academic performance. In this study we gathered scores of premedical examination and i-RAT, we identified that the upper percentile students with highest scores in premedical examinations struggled the most in their first year of medical studies as indicated by their low i-RAT scores in first week of team based learning activity. N e ga t i ve a s s o c i a t i o n b e t w e e n p re m e d i c a l examination scores and first week i-RAT proved that high scorers lack in performing their best on entering medical college. Literature is also in favor of our finding where the MDCAT scores are not a determinant of good performance in initial 17 preclinical years. Low scores in first week activity showed that high st scorers struggled in their 1 year of medical collages. This factor is documented as one of the tool to Figure 1: Comparison between i-RAT 1 and Premedical Examination Scores Table I: Intergroup Comparison of p Values of i-RAT 1 and Average i-RAT Significant increase is seen in progressive iRAT scores in all 3 groups, with maximum improvement seen in fifth and sixth week and minimum improvement is seen in upper percentile group when compared with the group B and C . Negative linear association (r= -0.2) was found between premedical examination scores and i-RAT 1 scores of whole class with significant p value < 0.05, while very minimal negative association (r= -0.15) was found between premedical examination scores and average i-RAT with non-significant p value by using bivariate Pearson Correlation. Negative Figure 2: Progressive i-RAT Scores in 6 Weeks TBL Activities JIIMC 2023 Vol. 18, No. 2 141 Individual Readiness Assurance Test (i-RAT) https://doi.org/10.57234/jiimc.june23.1534 identify students who might be at risk to suffer in 18 initial academic years. Individual readiness assurance test is utilized to identify these high scorers early in their academic years to give them early support to sustain their good performance in preceding clinical years. Positive association between first week i-RAT and average i- RAT is in favor of the fact that the identified students maintain their performance and this factor can be taken as a tool to predict their future performance. 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Accounting Education. 2019;28(2):195-219. https://doi.org/10.1080/09639284.2018.1535986. 19. Ahmady S, Khajeali N, Sharifi F, Mirmoghtadaei ZS. Factors related to academic failure in preclinical medical education: A systematic review. Journal of Advances in Medical E d u c a t i o n & P r o f e s s i o n a l i s m . 2 0 1 9 ; 7 ( 2 ) : 7 4 . https://doi.org/10.30476%2FJAMP.2019.44711. JIIMC 2023 Vol. 18, No. 2 142 Individual Readiness Assurance Test (i-RAT) https://doi.org/10.57234/jiimc.june23.1534 CONFLICT OF INTEREST Authors declared no conflicts of Interest. GRANT SUPPORT AND FINANCIAL DISCLOSURE Authors have declared no specific grant for this research from any funding agency in public, commercial or nonprofit sector. DATA SHARING STATMENT The data that support the findings of this study are available from the corresponding author upon request. This is an Open Access article distributed under the terms of the Creative Commons Attribution- Non- Commercial 2.0 Generic License. JIIMC 2023 Vol. 18, No. 2 143 Individual Readiness Assurance Test (i-RAT) https://doi.org/10.57234/jiimc.june23.1534