Advances in medical education and practice: student perceptions of the flipped classroom

Figures & data

Table 1 Characteristics of the traditional classroom, the FC, and the undergraduate medical education FC based on studies from this review

	Phase 1 – content orientation	Phase 2 – application of knowledge
Traditional classroom
Students: passive learners Teachers: Sage on the Stage	Classrooms are dedicated to lecture-based teacher-centered activities	Students may apply knowledge from prior lectures to “homework assignments” (independent application, outside the context of peer or faculty interaction)
Flipped classroom
Students: active learners Teachers: Guide on the Side, facilitating student inquiry	Through “homework”, students are introduced to basic content via online resources	Classrooms can now be dedicated to creating active learning environments that foster deeper learning. Students may tackle more challenging concepts in the context of working with their peers and with access to faculty
Undergraduate medical education FC
Elements utilized in medical education FCs from reviewed studies	Lecture videos, podcasts, formative quizzes, e-learning modules	CBL, TBL, PBL, small group discussions

Abbreviations: FC, flipped classroom; CBL, case-based learning; TBL, team-based learning; PBL, problem-based learning.

Figure 1 PRISMA style schematic for our scoping review.

Table 2 Studies that characterized medical student perceptions to FC approaches in preclinical subjects

Study authors, year	Subject matter (learner level, if described)	Primary pre-session online resources	In-session active learning activities	Comparison group	Main outcomes from flipped elements
Prober and Heath,^Citation11 2012	Biochemistry (M1)	Video lectures	Discussions of clinical vignettes	Previous cohort (LB)	Positive effect on student perceptions and attendance
de Fatima Wardenski et al,^Citation12 2012	Biochemistry (M1)	Lecture slides, audiovisual resources, bio-informatics tools, scientific papers	Forums for small group work	None	Students perceived benefits related to knowledge and motivation to learn and need for greater support/direction for both pre-class and in-class activities
Veeramani et al,^Citation13 2015	Clinical neuroanatomy (M1)	Web-based modules and text-based resources	Clinical case-based discussions	Previous cohort (LB)	Performance on examination improved; students perceived increased engagement and stated preference for FC relative to didactic lectures
Morton and Colbert-Getz,^Citation14 2016	Anatomy (M1)	Video lectures, workbook assignments	Large group discussion (think, pair, share) approach to problem sets	Previous cohort (LB)	No difference on knowledge-based items, but increased performance on items that assessed higher levels of cognition
Whelan et al,^Citation15 2016	Anatomy (M1 and M2)	Audiovisual resources, lecture slides	Modified TBL (student-driven approach to small group learning)	Faculty-driven approach to small group learning	Appreciation for benefits of student-centered learning, but active learning environment was highly variable between groups
Grossman et al,^Citation16 2015	Humanities, narrative medicine	Multimodal modules	Interactive activities (eg, construct narratives based on online information)	None	Positive student perceptions regarding engaging learning environment
Evans et al,^Citation17 2016	Epidemiology (M1)	Lecture videos, texts, and lecture slides	Case-based small group discussions	Previous cohort (LB)	Increased student satisfaction with small group activities, but no impact on examination performance
Sharma et al,^Citation18 2015	Rheumatology	Lecture videos	Hybrid approach incorporating TBL and CBL	None	Positive student feedback (vaguely described)
Sajid et al,^Citation19 2016	Hematology (M3)	Lecture videos	Application of knowledge exercises	Previous cohorts (LB)	High levels of satisfaction; no impact on examination performance
Nelson et al,^Citation20 2016	POCUS (M1)	Lecture videos	Interactive, hands-on session using POCUS	None	Both students and faculty expressed value for initiative

Abbreviations: FC, flipped classroom; TBL, team-based learning; CBL, case-based learning; M1, first-year medical students; M2, second-year medical students; M3, third-year medical students; POCUS, point-of-care ultrasound; LB, lecture-based or teacher-centered approach.

Table 3 Studies that characterized medical student perceptions to FC approaches in clinical education

Study authors, year	Subject matter (learner level, if described)	Primary pre-session online resources	In-session active learning activities	Comparison group	Main outcomes from flipped elements
Patwari and Yiu,^Citation21 2014	Emergency medicine (M3)	Lecture videos	Active learning on wards	None	Positive overall reception toward online resources, with some caveats noteda
Lew,^Citation22 2016	Emergency medicine clerkship (M3 and M4)	Lecture videos	Case-based small group discussion	None	Student surveys report preference for flipped approach vs lectures; facilitators reported perceived high levels of student engagement
Ilic et al,^Citation23 2013	EBM (M2)	Self-directed learning tools (including lecture videos)	Facilitated workshop (with journal club elements)	Control group (LB)	Berlin tool (quantitative objective assessment of EBM competency) did not indicate an effect, though self-perceived skills in specific areas were improved; qualitative data from focus groups indicated benefits (self-directed learning) and limitations (lack of student preparedness)
Ilic et al,^Citation24 2015	EBM (M3)	Online self-directed learning tools (including lecture videos)	Application of knowledge activities on wards	Randomized control group	No impact on learning or skills; positive effect on attitudes toward EBM (surveys) and the use of EBM in clinic (self-reported)
Gillespie,^Citation25 2016	Obstetrics and gynecology clerkship (M3 and M4)	Lecture videos (narrated presentations)	PBL sessions	Previous cohort (LB)	Flipped approach led to increased performance on various assessments (exams and OSCEs), but led to reduced scores on gynecology-related items on exams
Morgan et al,^Citation26 2014	Obstetrics–gynecology (M4)	Videos and readings	CBL sessions	Didactic components of same course	Students preferred flipped elements over didactic elements; knowledge increased (pretest vs posttest)
Morgan et al,^Citation27 2015	FC approach to obstetrics–gynecology (M4)	Videos, narrated presentations	CBL sessions	Previous cohorts (LB)	Flipped elements were positively received (student surveys); no evidence of knowledge gain (NBME results)
Liebert et al,^Citation28 2016	Surgery clerkship	Video lectures	Review of pretest, case-based clinical reasoning	Previous cohorts (LB)	Self-reported increases in interest in surgical careers; no difference in NBME results
Liebert et al,^Citation29 2016	Simulation-based surgery clerkship	Video lectures	Review of pretest, case-based clinical reasoning	None	Perceived benefits related to self-directed learning, student accountability
Bosner et al,^Citation30 2015	Primary care diagnosis skills (M4 and M5)	Video and audio-recorded lectures	Interactive small group laboratory exercises	None	Positive student perceptions toward interactive small group approach; interest and engagement were also enhanced per student surveys and focus groups; knowledge gained (pretest vs posttest)
Belfi et al,^Citation31 2015	Radiology clerkship (M3)	Interactive modules, games, and simulator	Modified approaches to CBL and TBL	Didactic components of same course	Student surveys characterized positive perceptions to flipped elements relative to didactic elements; knowledge increased (pretest vs posttest)
O’Connor et al,^Citation32 2016	Radiology clerkship (M3 and M4)	Web-based tutorials	Interactive workshops	Control cohort (LB)	Increased enjoyment, task value, and reduced boredom (student surveys) and better student performance; instructors noted preference for FC approach
Duque et al,^Citation33 2013	Geriatric medicine (M3 and M4)	e-Learning modules, video game	Weekly case conference with interprofessional team	None	Approach led to positive attitudes regarding geriatric medicine; knowledge increased (assessed via pretests vs posttests) as a function of modules
Ingrassia et al,^Citation34 2014	Blended learning approach to disaster medicine (M4–M6)	e-Learning modules	Workshops including PBL and simulation activities	None	Student surveys characterized generally strong perceptions; knowledge increased (pretest vs posttest)
Boysen-Osborn et al,^Citation35 2016	Advanced cardiac life support	Podcasts	TBL activities	Previous cohorts (LB)	Small improvements in examination results
Robinson,^Citation36 2016	Medicine as business elective (M4)	Online videos	Small group discussion-based activities	Subsequent cohort with MOOC approach	Student evaluations were similar for MOOC and FC approaches

Note:

a Student perception data related to this innovation was derived from personal communication (Yiu et al, 2016).

Abbreviations: FC, flipped classroom; TBL, team-based learning; CBL, case-based learning; M1, first-year medical students; M2, second-year medical students; M3, third year medical students; M4, fourth-year medical students; M5, fifth-year medical students; M6, sixth-year medical students; EBM, evidence-based medicine; LB, lecture-based or teacher-centered approach; MOOC, massive open online course; NBME, National Board of Medical Examiners; OSCEs, Objective Structured Clinical Examinations.

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