Our understanding of immunology in medicine has deepened due to the immune system's role in various diseases. Immunology has evolved into a unified framework for understanding disease mechanisms across multiple organ systems, highlighting the connections between disease processes. This evolution in understanding of the importance of the immune system has led to a broader comprehension of conditions like cancer, heart disease, rheumatological disorders, host-pathogen interactions, and the treatments targeting these diseases (Kuwabara et al., 2017; Yap et al., 2018; Zheng et al., 2020; Zhao et al., 2021). Understanding the integration of immunology with other systems and disciplines is critical but challenging for first-year undergraduate medical students (Lee and Malau-Aduli, 2013; Melnyk and Mikhnenko, 2020). Given the dynamic, interdisciplinary nature and redundant network of interactions necessary for normal system functioning and disease recognition, it is easy to understand why medical students find immunology one of the more challenging disciplines in their curricula (Siani et al., 2024). Thus, it is essential to employ learning modalities to help students visualize this complexity.

Complexity in medical education content leads to information overload and cognitive burden for students (Szulewski et al., 2021). Best practices for reducing cognitive burden require structured information sequencing, tracking learning progress, and incorporating feedback mechanisms to optimize comprehension and retention (Van Gog et al., 2005). Active learning exercises that combine structured learning strategies, visualization techniques, and cognitive scaffolding practices are beneficial. Indeed, exercises that enhance retention and application of immunology concepts and shift the teaching process from a teacher-centric to a learner-centric approach are of greater value (Freeman et al., 2014; Lombardi et al., 2021).

Several active learning modalities are employed in medical education. For instance, case-based learning (CBL), problem-based learning (PBL), and team-based learning (TBL) have all been recognized as active learning approaches that naturally integrate these practices (Alexander et al., 2024; James Trill et al., 2024; Kamal, 2024; Shang et al., 2025). TBL in particular is reported to potentially outperform other active learning techniques in long-term knowledge retention and foster higher student engagement due to structured peer discussions, readiness assurance tests, and application-based exercises (Slavin, 1996; Chytas et al., 2023; Alizadeh et al., 2024). While CBL and PBL encourage inquiry, TBL ensures deeper conceptual understanding and provides a guided approach to knowledge acquisition (Burgess et al., 2021; Roossien et al., 2022; Burgess and Matar, 2023). We chose a TBL application exercise to incorporate concept mapping for these reasons.

Concept maps are a powerful metacognitive tool that enhances learning by organizing and linking concepts in a visual representation and have proven beneficial in educating students, including medical students, about immunology (Sannathimmappa et al., 2022; Izci and Akkoc, 2024). Concept maps require students to activate prior knowledge and cognitive processes (Novak and Cañas, 2006). These maps are traditionally created using concepts enclosed with linkers connecting them, and a phrase indicating the relationship between the concepts (Novak and Cañas, 2006). Generally, concepts should be arranged hierarchically, with more inclusive concepts toward the top (Novak and Cañas, 2006). However, concept maps have evolved to include a variety of designs that move beyond simple hierarchical organization. More recently, concept maps have incorporated images or web links and are generated through collaboration with other learners (Eachempati et al., 2020), thereby enhancing map quality (Kwon and Cifuentes, 2009). This creative flexibility enables the map to approximate how a learner visualizes information more closely. Crucial to the efficacy of this visualization is the proximal delivery of structured educator feedback to the mapping activity. In an evaluation involving physiotherapy students, Joseph et al. demonstrated that formative feedback led to a more profound understanding of the material, as determined by applying Kinchin's classification (Kinchin et al., 2000; Joseph et al., 2017). This work supports the use of concept mapping as both a diagnostic tool and a method for addressing misconceptions and deepening knowledge frameworks. The use of structured feedback also complements the collaborative nature of TBL among peers, students, and their instructors.

Concept mapping aligns with generative learning theory (GLT) and, when paired with Team-Based Learning (TBL), follows social constructivist theory, where knowledge is constructed through social interactions (Alt and Naamati-Schneider, 2021; Dong et al., 2021; Oluwatosin et al., 2022). Indeed, mapping has been used successfully to reinforce intellection in a modified collaborative concept mapping (CCM)/TBL format (Knollmann-Ritschel and Durning, 2015). Employed in the final phase of TBL as a team application exercise, concept mapping encourages collaborative construction of knowledge within stable teams, allows for immediate peer discussion and feedback to reinforce retention, and helps teams synthesize information from pre-class preparation and in-class discussions into a meaningful visual conceptual framework.

This activity aimed to develop a TBL session incorporating CCM to assess students' understanding of core immunology concepts, integrated with a microbiology topic. Our aims were to 1) evaluate the utility of concept mapping within a TBL framework, 2) assess student perceptions of this active learning approach, 3) identify conceptual integration patterns and learning gaps in our students, and 4) explore modifications for optimizing a CCM-TBL model within our curriculum.

Medical students often find immunology challenging to understand and report disliking the subject (Lee and Malau-Aduli, 2013; Haidaris and Frelinger, 2019). There are numerous caveats, discoveries, and various cells and signaling molecules with conflicting behaviors and responses that depend on the pathogen, timing, genetics, and body system. Moreover, many students enter medical school with little to no experience with formally studying the immune system, as only 18% of US Medical Schools require immunology for entry (Reynolds et al., 2022). Students must grasp immunology, as it is integrally connected to the function of body systems and the ability to respond to pathogens. Therefore, it is necessary to employ modalities that integrate topics and allow learners to construct a more comprehensive framework for understanding immunology within the context of other disciplines. To achieve this, we utilized collaborative concept mapping in a Team-Based Learning (TBL) format (CCM-TBL). This approach provides a stimulating and collaborative learning experience for medical students, enabling them to pinpoint areas where they lack understanding of complex microbiology and immunology subjects (Tables 2, 4).

Now more than ever, medicine is a team enterprise, as specialties and allied health contributions have advanced to the point where no single individual can possess all the knowledge needed to optimize patient care. Recognition of team learning has risen in prominence so that the Accreditation Council for Graduate Medical Education, the accrediting body for residency and fellowship programs, now has it integrated into its core competencies and the Liaison Committee on Medical Education, the accrediting body for medical education in North America, emphasizes the principle for students to develop collaborative skills (ACGME Core Competencies | Graduate Medical Education | Stanford Medicine, n.d.). The act of collaboration enhances learners' ability to grasp complex topics, such as immunology. This may be due to learners having to articulate their scientific knowledge. CCM-TBL enables students to develop their collaborative skills by leveraging their collective wisdom to construct concept maps.

This dependence on social interaction, reflection, and integration of new and prior knowledge results in CCM-TBL being consistent with generative learning and social constructivist theories. Generative Learning Theory (GLT) emphasizes the construction of new knowledge by integrating existing knowledge with new information (Wittrock and Farley, 2010). It encourages learners to elaborate on the meaning of the new construct. Constructivist theory suggests that learners build meaning and understanding through personal experience and reflection, while social constructivism emphasizes the role of social interactions and collaboration in developing concepts, often through community-based discussions (Sharma and Shukla, 2023). In this exercise, instructors initially directed students to think about how the immune system typically responds to a fungal infection and how HIV interferes with this response. Students explored this topic through class discussions led by faculty and then within their TBL teams. Students collaboratively utilized relevant frameworks to answer the focus, incorporating many key concepts in microbiology and immunology identified in Figure 3. Students engaged in discussion with peers and faculty as faculty visited groups to correct misconceptions and check in with students. Students also collaborated with faculty to create a class consensus map.

Small-group learning strategies and TBL in particular focus on collaborative knowledge acquisition. TBL was first adopted in medical education in 2001. Its scaffolded activities emphasize applying existing conceptual knowledge to new challenges, offering students the ability to determine their level of competence and rely on a network of peers to fine-tune their understanding. When moving through the TBL exercise, students can apply their existing knowledge to real-world problems, giving their knowledge relevance. Students eternally seek to understand the significance of the information they are exposed to in order to make meaning in their lives (Michaelsen et al., 2002). For this reason, the application exercise is an essential penultimate component of the TBL activity. Moving from knowledge to application can be more challenging for more abstract concepts.

Immunology is more of an abstract science, given the difficulty in easily visualizing the complex interactions between the multitude of players, which possess a challenging nomenclature. The process of concept mapping is rooted in constructivist theory, which enables the visualization of complex, abstract concepts. Students rely on prior knowledge to make connections between topics and then illustrate these connections (Novak and Cañas, 2006; Naeem Sarwar et al., 2024). Mapping these interactions relevant to an infectious disease case allows students to apply abstract knowledge. Students benefit significantly from developing strategies to organize and integrate new information with their prior knowledge across disciplines, which this modality encourages. Together, our data suggest that CCM-TBL is effective in allowing learners to recognize their learning gaps and work collaboratively with peers to address them, thereby reinforcing the integrative learning process through this modality.

While learners found CCM-TBL helpful in identifying weaknesses in their knowledge, fewer students endorsed using concept maps in TBL (Tables 4, 5). Our results differ from the findings of Sannathimmappa et al., who found that 80% of undergraduate medical student respondents agreed that concept maps were enjoyable and interesting (Sannathimmappa et al., 2022). This difference may be due to students self-selecting to participate in this latter study and completing a concept mapping orientation session that described their importance and the roles of students and teachers. Another difference is that those medical students also participated in a session where they were provided with premade concept maps and explored them together. Similarly, we found that student satisfaction with using concept maps increased when we offered an example concept map (see Supplementary material 2). Moreover, even though we offered an optional video describing concept mapping as a part of the preparation material for the session, many of our learners created non-traditional maps. Student enjoyment may have increased if we had provided a concept mapping orientation session before the exercise, which will need to be explored in the future.

Beyond student perceptions of satisfaction with this modality, there was the suggestion that integrating concept mapping with TBL led to detectable shifts in the depth of student understanding of the immunology concepts. While it cannot be attributed solely to the concept mapping activity alone, the increase in the disappearance of Spoke maps and rise of Net maps reported in Table 3 likely reflects improved instruction or curriculum change, leading to deeper conceptual understanding and in any event, applying all facets of instruction regarding the immunology and microbiology concepts covered improved student understanding.

Our findings suggest implications for medical education policy and practice. Early initial integration of CCM-TBL into foundational medical sciences curricula, particularly in courses that present topics with abstract complexity, can facilitate integration of multiple discipline domains, such as immunology, with other basic and clinical sciences. Furthermore, the adoption of concept mapping in TBL can demonstrate to students a tool they can use to self-assess the depth of their understanding during the studying process, beyond serving as an active learning synthesis exercise in the classroom. Using concept mapping to support students in self-directed learning aligns with the LCME's emphasis on this element. Additionally, our results suggest that concept mapping can be used to assess the depth of student understanding and inform faculty considerations for curricular revision. It is recommended that faculty development programs instruct educators on the potential assessment benefits that concept mapping can provide, particularly in a TBL format. Lastly, CCM-TBL serves to further collaborative and team-based learning professional skill development in students, as advocated for by the LCME and ACGME.

This CCM-TBL educational method is an engaging learning modality for the next generation of health professionals. Students built upon prior knowledge to connect immunology and microbiology, and self-identified misconceptions regarding the immune response against HIV. While collaborative concept mapping in a TBL format allowed students to identify weaknesses and clarify concepts, student perceptions were mixed regarding the suitability of the format, and many students preferred a standard MCQ-based session (Figure 4).