No Flipping Way in MedEd

“Flipping the classroom” is a trendy educational technique that has entered the lexicon of almost every medical school that I know. I have even moderated sessions on “flipping the classroom” at conferences and meetings. The problem is that in medical education, we do not flip the classroom and to pretend we do is a great disservice to our learners.

The initial concept of “flipping the classroom” starts with the idea that in K-12, students are taught specific concepts in the classroom and then go home and do assignments (homework) to solidify those concepts. When one “flips” the classroom, the students work on learning specific concepts on their own at home and then solidifies these concepts by practices in the classroom setting where a faculty member is available and can mentor the student working on the concepts that they are supposed to learn.

Technology has been cited as a key factor in the “flipped classroom.” I disagree. When I was in school, we often had quizzes at the beginning of class on material we were supposed to have learned on our own so that we could participate in the discussion of the subject at hand. In team-based learning (TBL), learners are expected to prepare before coming to the session and are assessed with the readiness assurance tests (RAT; iRAT; tRAT). This is fundamentally part of the concept of having “reusable learning objects” that learners use to prepare themselves for classes.

Now, we use pre-made, special, short videos for flipping classrooms. Technology has made flipping the classroom easier – especially for those faculty who just “show last year’s lecture.” But, it does not fundamentally alter the idea that learners prepare for class by reviewing resources ahead of time.

What the flipped classroom does provide is time for learners to learn skills associated with thinking through the subject at hand. It is an opportunity to be active in the learning process. Depending on how the session is developed, learners can develop skills such as identifying what they need to learn, research the topic, and evaluate the resources to come to an understanding of the information about the topic. Without question, this is a valuable model for education, regardless of educational level.

However, in the typical setting, flipped classrooms presuppose several things:

  1. There is a finite amount of material that is introduced and for which the learner achieves a level of mastery in the classroom setting.
  2. Learner assessment is based on their achievement of mastery of the introduced concepts – and they are not expected to learn additional related material to do well on their assessments.
  3. There is a defined timeframe for the material to be introduced (classroom) and assignment (homework) that can be flipped. Consequently, the total time involved between “classic” and “flipped” models is the same.

None of the above presumptions are true in medical education. And using the term “flipped classroom” with our learners is thus misleading.

There is no predefined finite amount of material that is adequate for mastery in medical school. Medical school material is about the application of fundamental scientific knowledge and thinking processes for clinical application. Thus, in a preclinical active “flipped classroom” environment, one approach would be for students to study the fundamental scientific knowledge at home prior to the class and then have the class session as a time to apply the material to clinical issues. The challenge is that the learners do not have the depth of knowledge to develop more than the most rudimentary components of mastery. So, in medical education, the best we can do is to have learners develop skills toward their mastery, but mastery is accomplished outside this setting.

However much we want to reduce the amount of information medical students are required to know in our courses and programs, we are constrained in that they must know enough to pass their licensure exams (USMLE; COMLEX). Thus, we have no choice but to teach the information and assess the learners or else leave them to their own devices to make sure they pass the licensure exams. Now, I think we have an obligation to prepare the learners for their licensure exams, but not all medical educators agree with me. We cannot ensure that the learners master everything they need in a topic from each flipped classroom experience. In my experience, we usually have to limit the amount of information provided to learners for a “flipped” experience as compared to a lecture on the same topic. Thus, they are exposed to even less than we might expect of them in our own course assessment, much less the licensure exams.

Almost no faculty member in medical schools assigns homework in the classical sense. Traditionally, we give a lecture (an hour?) – which often is optional, suggest some readings, and expect learners to be able to figure out what they need to know for the exam. Thus, the time commitment for the session is the class session time and then whatever is needed for the learner to achieve the appropriate level of mastery of the subject at hand.

In the typical “flipped classroom” model in medical education, we ask learners to prepare by viewing a required video ahead of time (an hour?), require attendance at the flipped session (another hour?), and still expect the learner to commit whatever is needed to achieve the appropriate level of mastery not only for the material covered, but for everything else they need to know to pass the course and/or licensure exams.

From the learner’s perspective, we have moved from one optional hour to two required hours and no change in what is expected of the learner. Thus, from the learner’s perspective, we have simply increased their load by a minimum of two additional hours. This seems to be unfair to them and, quite frankly, I can’t argue with that perspective.

From the perspective of a medical education administrator, we have added an hour of required curriculum time. In most of our medical schools, we are “hour neutral,” meaning that we cannot add an hour without taking it away from somewhere else in the curriculum. Depending on what the defined outcome is, it is not clear what we have gained besides being able to use a buzzword.

Am I arguing that we should not require learners to prepare before the educational session and to devote the educational session to an active participatory exercise? No, most emphatically not. What I am saying is don’t call it a “flipped classroom.” Even more importantly, don’t use it as an underhanded way to add curricular hours. Rather, use this opportunity to instill in the learners the skills that are being addressed and to test the development of those skills in our assessments.

We do not teach “flipped classrooms” in medical education. What we do is ask learners to start developing specific cognitive skills that aid in their clinical training. In our courses/clerkships, we need to tell the students of the specific skills that they should be developing. We should call the session by what it is – developing specific skills – than what it is not – a “flipped classroom.”

In summary, the term “flipped classroom” in medical education is a misnomer; it leads to confusion and resentment in students. I argue that we should be working with students to learn techniques of thinking through clinical applications of knowledge gained and acquired outside the classroom – and show them through assessments how those skills can be used.

Note: The views in this commentary are my own and not necessarily those of my institution, employer, or colleagues.

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