1. Introduction 
The current trends in medical education show a change of teaching-learning methods from the traditional teacher-center one where the role of a teacher is a “Sage on Stage” as knowledge provider to a more student-center one where the teacher acts more like a “Guide by the Side” [1]. Students too are expected to shift from a state of passive dependency to active, self-directed learning, working towards the role of Indian Medical Graduate (IMG) as a life-long learner, as directed by Medical Council of India (MCI) in “Vision 2015 document” [2].
Cooperative learning is one such avenue of teaching method which supports active learning, where a small group of students works with a set of learning objectives to reach a common goal. Here, the learner is responsible not only for his learning but also for others’ learning. The main approaches to cooperative learning used in recent decades include student team achievement divisions, team-games-tournaments, team-assisted individualization, and jigsaw. In some of these approaches, the learners may do their tasks as a group, while in other approaches, the tasks are divided among the members of a group, and each member works independently and only asks for help if needed [3, 4, 5]. 
Jigsaw teaching method, created by Aronson and Bridgeman, Santa Cruz professor at the University of California, is one of the types of cooperative learning [6]. This method guides the students to search, learn and train each other [7]. This method has shown improvement in comprehension, knowledge, problem-solving clinical skills, self-confidence, and communication. Few studies compare the effectiveness of cooperative learning methods like jigsaw with traditional small group teaching.
Aims and objectives 
• To compare the effectiveness of the Jigsaw teaching technique with the small group teaching method (i.e., mini-interactive lecture) among phase 3 MBBS students in the Department of Pediatrics.
• To assess student perception of the jigsaw method.
2. Materials and Methods 
Setting
Department of Paediatrics, DM WIMS, Wayanad
Design
An experimental study with crossover
Subjects
Phase 3 MBBS (Bachelor of Medicine and Bachelor of Surgery) students, Paediatrics Department
Sample size
A total of 30 students, as a small group teaching method (supplementary batch of the third MBBS students), were enrolled after obtaining their informed consent. They were randomly allocated into small group teaching group (n=15) and jigsaw group (n=15) by the lottery method. All participants underwent 8 exposures (4 topics of similar difficulty level).
Data collection
After Institutional Research Board (IRB) clearance and taking informed written consent from participants, the students were randomly allocated to 2 groups: A) small group teaching and B) Jigsaw group (15 students in each group). Four topics were decided for the 4 sessions (cerebral palsy, Acute Kidney Injury [AKI], nephrotic syndrome, and approach to hemolytic anemia). For the small group teaching, 15 students were taught using a mini-interactive lecture. The mini-interactive lecture is not just a small group didactic lecture, but the students were encouraged to participate and apply their knowledge to a case/problem based on the lecture. On the same day, the jigsaw group had the same topic taken using the jigsaw technique. At the end of their class, both groups were given a validated post-intervention test, and their marks were tabulated. Student evaluations were assessed using a 5-point Likert scale for the jigsaw group. Next time, there was a crossover, and group A became the jigsaw group and B the small group teaching one, eliminating ethical conflicts.
Method
In each case, the subjects that were supposed to be taught using the jigsaw technique were split into sections of equal difficulty with no overlaps, as in accordance with the requirements of the jigsaw technique. Every student was given a sheet of paper containing details of the subject they need to master, a series of information about it, and proper references to be studied a day before the class. On the day of the class, they initially assembled as home groups. Expert groups were then formed to discuss and exchange ideas on the subject assigned to them for 20 minutes. The discussion was supervised and facilitated by the teacher. Each member of the expert groups then returned to their initial groups and taught the part assigned to them to the other members of that group. The topic was then discussed with a case scenario, and then assessment was done by Multiple Choice Questions (MCQs) (out of 10), and the scores were tabulated. The same teacher took all sessions (Figure 1). 3. Results 
The study was conducted on 30 students, divided into two groups: A) the jigsaw group, and B) small group teaching of 15 students each. After their respective classes, they were given a test, and the scores were tabulated. Descriptive analysis was done by calculating the mean of the post-intervention scores and then inferential analysis using the independent t test in SPSS 15. P<0.05 were considered significant. The jigsaw group were then given questionnaires to fill out. A total of 4 sessions (8 exposures) were done on the topics of cerebral palsy, acute kidney injury, nephrotic syndrome, and approach to hemolytic anemia. The observations were as follows: 
Test score comparison
As seen in the Table 1 on the test scores of the four sessions and the final depiction in the bar diagram, the post-intervention scores of the jigsaw group are significantly higher than the small group teaching group, with all being statistically significant with a P of less than 0.05, and 3 of these sessions having a P of less than 0.01 making it statistically very significant (Figure 2). Student evaluation of Jigsaw teaching
It was assessed by a 5-point Likert scale containing “strongly agree” =5, “agree” =4, “neutral” =3, “disagree” =2, and “strongly disagree” =1.
The above diagram shows the different scores on the various statements using the Likert scale. Of all the statements, easy understanding of the topic seems to have the highest scorer, showing that students found jigsaw teaching an excellent method to enhance understanding of the topic, followed by finding it an interesting method. The students generally evaluated the jigsaw method as an effective way of teaching/ learning which they found beneficial. On the downside, students were skeptical about its usefulness in helping retain it for the long term. Comparing the mean test scores of the jigsaw and the small group discussion, the jigsaw teaching emerged as the clear winner, and the students’ opinion of the jigsaw method seems to be promising (Figure 3). 4. Discussion 
With the Competency Based Medical Education (CBME), teaching has taken a paradigm shift towards student-centered learning, problem-based learning, integrated teaching, community-based education, elective studies, and a systematic or planned approach model where many innovative teaching-learning) methods are being probed into to improve student-centered learning. The need for this approach comes from the many shortcomings of the traditional lectures, which paved the way to use small group discussions. Though this approach was a bit more effective, it was still a small group lecture in most scenarios. To overcome this problem and find newer methods to promote self-directed learning, active involvement, and better subject understanding, which might plausibly work in our setup, this study compared jigsaw teaching with a small group discussion. 
According to the results, jigsaw teaching clearly showed better student performance when compared to small group discussion. This result follows some prior studies like Srivastava et al., who studied the effect of interactive intra-group teaching. They found a significant difference in the post-intervention scores by the interactive method as compared to the traditional teaching method [8]. Saleh et al. compared didactic lectures with interactive sessions in small group teaching and found that students performed better in interactive sessions. They also found a positive attitude among students toward interactive sessions [9]. Parmar and Rathod also observed a significant increase in mean post-intervention score for the innovative teaching methods for all topics [10]. Eachempati et al. reported that the posttest revealed a significant difference between the two groups as students in the experimental group (jigsaw) enjoyed greater success by helping each other, as well as a greater exchange of information than they had experienced in traditional teacher-centered lectures [11]. Bertucci et al. reported that cooperative learning promoted higher achievement and greater academic support from peers than did individualistic learning [12]. Sanaie et al. reported that the jigsaw technique helped improve students and self-regulated learning and academic motivation [13]. Bogam and Khan have mentioned that jigsaw methodology can make a significant gain of knowledge in medical students regarding diabetes mellitus type 2 [14]. Walker et al. reported that the jigsaw method of peer teaching is an educational and enjoyable way to teach [15]. The point to be noted here is that most of these studies compared jigsaw with the traditional teaching, and the jigsaw method emerged as a clear winner.
This finding is contrary to some studies like Puppalwar and Jambhulkar [16], and Sagsoz et al. [17]. They reported no difference in scores between the jigsaw group and traditional lecture group. Anderson et al. showed no significant difference between jigsaw and lecture in biochemistry lessons in medical students [18]. Moskowitz and Nash [19] showed that the use of the jigsaw method had no positive effect on learning.
This study also involved taking students’ evaluations. It showed a positive response concerning better topic understanding, communication skills, student satisfaction which is in line with other studies with similar experiences. Studies like Phillips and Fusco's study [20] showed that students’ opinion on this method is positive, and they prefer to experience this method more in their courses which represents an increase in student satisfaction [21, 22]. This teaching method also develops self-confidence [23], communication among students, student support, logical thinking, problem-solving ability, motivation [24], and critical thinking [23]. Studies confirm the effectiveness of participatory methods such as jigsaw on the learning of academic disciplines at different levels and in various courses [21].
In Leyva-Moral and Camps's study, students’ satisfaction with jigsaw teaching was low. In his research, most students believed that jigsaw teaching should not be used in the future, and it was not more effective than traditional methods. Students said that they could not take notes, and this shortcoming brings about insecurity [25].
5. Conclusion
Based on students’ preferences, performances, and positive acceptance of the method, we recommend that this interactive and proactive technique be adopted in teaching. It helps provide another method to add to our bag of tricks as we embrace the CBME and aim at the holistic development of the IMG. It is also important that faculty be sensitized and trained to implement this method effectively.

Ethical Considerations
Compliance with ethical guidelines
There were no ethical considerations to be considered in this research.

Funding
The study is self-funded.

Authors' contributions
Study concept and design: Vidya Singaravelu & Madhusudhan U; Acquisition of data: Vidya Singaravelu; Analysis and interpretation of data: Vidya Singaravelu & Madhusudhan U; Drafting of the manuscript: Vidya Singaravelu & Madhusudhan U; Critical revision of the manuscript for important intellectual content: Vidya Singaravelu; Statistical analysis: Vidya Singaravelu & Madhusudhan U; Administrative, technical, and material support: Vidya Singaravelu; Study supervision: Vidya Singaravelu.

Conflicts of interest
The authors declared no conflict of interest.

Acknowledgements
We extend our sincere gratitude to dear students who wholeheartedly consented to participate in the study, thereby ensuring the smooth completion of the study.


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