What millennial medical students say about flipped learning

Figures & data

Figure 1 Summary of student responses to the prompt, “Slide the scale to indicate your preferred large group format. Slide the dial to any % flipped, from 0% to 100%.”

Notes: Flipped = typical lecture and homework elements of a course are reversed; video lectures are viewed by students at home before the class session, while in-class time is devoted to exercises, projects, or discussions (Association of American Medical Colleges, 2013). Lecture-based = lectures with activities built into some presentations.

Table 1 Summary of student responses to optional comments regarding preferred large group format

Theme	Specific comments
Pace	Flipped classrooms rush learning. People work at different paces, and flipped classrooms encourage rushed learning, especially when people blurt out answers; it makes you feel behind and inadequate. I feel like the flipped classroom does not work for me. It is usually group-based activities and the person who leads the group is very vocal and understanding of the material. I do not learn best being overshadowed in the content by my peers.
Organization	Flipped-based classes often are too unorganized due to large group sizes and other students blurting out answers, thus making them ineffective. I personally feel that many times with the in-class activities, there are too many students all trying to do the same thing, which makes it hard for individual students to learn and benefit from the activity.
Discipline-specific	I really enjoy activities for anatomy and embryology because it can be difficult to get proper understanding of how things work together. This depends on the material. For anatomy, the flipped works well, but for more dense topics in a subject like neurology, then flipped and lecture-based are well in 50/50. I think it depends on the content. For instance, dense topics such as biochemistry and physiology are probably best in lecture-based format. However, topics such as anatomy are best taught through activities in the flipped format. This really depends on the subject matter. For me, I like flipped for anatomy and micro courses as there is simply a bunch to memorize and the podcasts/vodcasts do a good job of this tedious stuff and then in-class activities for what we learned. However, courses like physiology, biochemistry, and genetics, I prefer regular lectures given in class. I do like the idea of these courses providing podcasts/vodcasts in addition to regular in-class lectures to explain harder concepts, but I do not want in-class activities for these subjects. Again, in-class activities for anatomy, micro, and clinicians are the only subjects I would like to see. I would also like to see more basic science lectures (biochemistry, genetics, pharm).
Schedule/Echo360™	Enjoy flipped classroom, however would prefer if they occur earlier in the week so there is enough time over the weekend to prepare for those classes. The only concern in having flipped is if we get the chance to preview the material. Will these exercises, projects, and discussions be ECHOed? I think a big reason why people choose not to go to class and to watch ECHO is because you can study at your own pace and study when you are at your sharpest. Not everyone is a morning bird. I would then recommend that the activities be in the middle of the day so that morning people and evening people can get the most out of it. (Also fits under Pace) The flipped classroom format is difficult sometimes to prepare for in time. I like it when there are activities worked into the lectures or using the last few minutes of lecture for an activity. That helps to cement the information of the lecture there and then and clarifies any gray areas. (Also fits under Lecture-based with activities)
Suggestions to enhance lecture based with activities	Keep things the way they are, may be a little more interactive lectures. I prefer receiving the lecture material in class and doing some built-in exercises to help the material commit to memory. When the podcasts given before lecture were short intros they were effective versus large sums of information that lecturers then just skipped over during lecture because they were “already discussed”. Some contents for the preview videos were good, while others were extra background information I did not find necessary. I did like the idea of the preview video. I would rather prefer the concept of still having lecture-based material presented, as it is this year, with the additional of short preview videos/lecture ahead of time.
Independent study	I prefer to view the lecture slides on my own and then come to class only to ask questions if I am confused on a certain topic. Of course, the main drawback to this is that the lecture slides must be absolutely 100% accurate and include everything that will be tested on. I prefer to not have podcasts if the lecture slides are accurate to read off of. I usually just outline my lectures from the powerpoint presentations and then listen to podcasts as necessary. Usually I do not physically go to large group unless its mandatory. I really dislike lectures, they are too passive, and for me, the challenge becomes less about the material and more about trying to discern which content this particular professor finds most important. I also feel that the only way to create sustained knowledge is to spend time reading and making connections with the material before interacting with a professor in a large group setting. I would prefer to have our time spent with professors discussing the topics, posing questions, and working through activities that connect that topic to other aspects/subjects required for the board exam. I would rather use the professors as a resource for deeper understanding of the material instead of reading their powerpoints to us. That just promotes Echoing simply because it is more efficient and you can turn 8 hours of lecture into 4–5 hours. Personally I gain greater sustained knowledge if I were to spend 4–5 hours reading.

Note: Echo refers to Echo360™ lecture capture technology.

Table 2 Summary of student responses to the open-ended prompt, “Please explain your choice”, that followed “For flipped sessions, should in-class practice activities be mandatory?”

Theme	Student explanation for selection of non-mandatory attendancea
Learning style	Reading assignments are more important. Not everyone can learn this way (8). Some people do not learn as well from activities, so their time might be better spent reviewing on their own (also fits under Not efficient) (2). I do not think they are necessary and I think that people can learn as much if not more if they do the activities themselves.
Attitude/Preferred learning conditions	When people are required to attend but do not actually want to be there, it ruins it for those of us who do want to attend. Activities would only be useful if the participant is willing to be there. Making attendance mandatory will limit some benefit. It is the student’s loss if not participating. Learning sessions should never be mandatory if ECHOed, we are in professional schools and student should be selected who are believed to uphold this professionalism. I like when it is less crowded and I think we can gauge where we need help. Forces us to be more self-accountable.
Not efficient	This would require far too much mandatory time if there were also outside lectures to watch. Very little time would be left for self-study. The activities often consume a lot of time that could be used more efficiently (3). Because it is still beneficial on Echo.
Choice	If people do not want to participate, they should not get the benefits of participating. People should have the choice of if they want to use in-class activities or their own activities to strengthen their understanding of material (also fits under Learning style). If the student does not feel that he or she needs additional practice, there should be no requirement to attend. Some people find them quite useful, while others can get more confused by not doing it “their way.” To me, flipped classroom activities are “study” if you do not find the particular one to be helpful, it may feel a waste of time (also fits under Learning style and Not efficient). It would of course be most beneficial to be in class for these activities and I think most students will gravitate toward attendance. But, I feel that there may be an occasion where you may have to miss class for an undisclosed reason or because you feel that you would prefer to learn that particular topic in a different manner. We are all professionals and we should be seeking the strongest level of understanding, thus the benefits of coming to class should stand on their own. It should not be “forced”, creating a fluid style of teaching will best suit all learning styles while still emphasizing what the school finds to be the most efficient way (also fits under Learning style).
Lack of preparation/time	Sometimes people are not prepared for the activities ahead of time and so do not get anything out of the session if they go. I like that classes are optional and if I am not prepared at a certain time there is no need to rush. Cannot attend them all.
Situation-dependent	Sometimes I do not find the large group practice activities helpful. My participation greatly depends on the professor in charge. They should be optional. For some of the subjects that I have already studied, the flipped sessions are not worth the time (also fits under Not efficient) (2). We are paying 50,000/year for medical education. Students will use their time as they deem most valuable to achieve academic success. Thus, in-class practice activities must have broad appeal and high yield to attract students to attend these sessions.
Pace	I still prefer going at my own pace. I like practice activities but I do sometimes feel like I take a backseat in group work. Other people come up with answers and I feel like I do not have as much time to work through problems on my own.

Notes:

a These comments were from students who selected non-mandatory. Echo refers to Echo360™ lecture capture technology. Parentheses refer to the number of additional similar comments obtained from respondents.

Table 3 Summary of student responses to the open-ended prompt, “Please explain your choice”, that followed “For flipped sessions, should in-class practice activities be mandatory?”

Theme	Student explanation for selection of mandatory attendancea
Motivation to attend	I think the activities are helpful, and if they were mandatory and given a specific allotment on time, I would be more inclined to go. (Rather than sitting in a large group lecture and not knowing if there were going to be practice activities or watching the lecture online and missing out on the activities.) To feel the obligation of being there. Non-mandatory makes the material feel unnecessary (2). I think if activities counted for part of the course grade, then I would be more likely to do them. But the activities have to be thought out very carefully because otherwise it might take time away from other studying.
Motivation to stay on top of material	Ensures that everyone actively participates, are prepared, and on top of their video lectures (4). This will allow me to make sure I have faculty available to ask questions and would allow me to make sure I complete the sessions in an orderly and timely fashion.
Application of knowledge	Primary knowledge is easy to learn independently, and practice with oversight instruction would confirm my knowledge (1). There is a need to future physicians of being able to see before clinic how cases, etc., are.
Promotes learning	Students are less likely to benefit from the activities if they do not attend (2). Interactivity better promotes learning. This is where content is solidified and confusion is rectified. It is vital.
Activity enhanced with increased participation	For many activities, having more participants makes the activity more enriching (such as competitive games). If they are not mandatory, then students will be less likely to attend and will not get the full benefits of having a flipped classroom. Also, it is a better learning experience when more students are present to participate (also fits under Motivation to attend)
Situation-dependent	If lengthy enough and worth attending, I believe in-class practice activities can be very beneficial. They must be well-structured, not a free for all, do whatever station you want. Yes, I think many in-class practice activities should be mandatory so that the essential content remains consistent for all students. However, there may be some subjects that may be more straightforward or review and there may be a significant number of students who may not benefit from additional practice activities. Especially if material from activities will be on test.

Notes:

a These comments were from students who selected mandatory. Parentheses refer to the number of additional similar comments obtained from respondents.

Figure S1 Flipped Preferences Survey

Abbreviations: AAMC, Association of American Medical College; SOMA, School of Osteopathic Medicine in Arizona.