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.

MedEd’s Role in Diversity

At my institution, recent events in the world around us led to students asking for an open forum on diversity issues at our school. This event was led by our Office of Diversity Enhancement (in the Office of Medical Education). Deans from the Office of Medical Education, the Office of Student Affairs, and Office of Admissions participated. The auditorium was packed with a standing room only crowd consisting of students, faculty, staff, and administrators.

As noted on the History web page of the Albert Einstein College of Medicine, “From the beginning, it has been the University’s policy that there be no discrimination in regard to race, religion, creed, color, national origin, sex, age, disability, veteran or disabled veteran status, marital status, sexual orientation, or citizenship status” (1).

Moreover, we are located in the Bronx, a racially diverse and low-income borough of the City of New York. In 2013 data from the U. S. Census bureau (2), the majority population (54.6%) was Hispanic, Latino, or Spanish origin and the largest minority population (43.3%) was Black or African American (most of whom are Black of non-Hispanic or Latino origin). The non-Hispanic or non-Latino White population represents only 10.5% of the population in the Bronx. The per capita income in 2013 was $18,171 and a median household income of $34,388. The percentage of persons below poverty level (2009-2013) was 29.8%.

The faculty (especially the clinical faculty) choose to work in this environment where their patients are challenged with numerous disparities and where compliance with medical care is not necessarily based on life style but a choice based on financial necessity.

Taken together, one would think that bias is minimal and diversity is maximal at Einstein. This, regrettably, is not the case. Let me be clear, it is not Einstein that is at fault; it is a systemic problem. However, we – medical educators – need to look ourselves in the mirror and ask how we have addressed the issue.

Diversity is challenging for all institutions. The Liaison Committee for Medical Education (LCME), the accrediting body for MD schools in the US and Canada, allows each institution to define their areas of focus for diversity in students and in faculty. The two categories need not be the same. Thus, medical schools can address diversity issues such as “GLBTI,” “veterans,” “economically challenged,” and “first college student in family” as areas of diversity. These areas are very important and need to be addressed.

While I have a very highly developed gaydar, I cannot reliably predict who is straight or GLBTI. Similarly, I cannot look at someone and know whether or not they are a veteran, economically challenged, first college student, etc. However, I can tell when their skin color is different from mine. However, the bottom line is that when I think of diversity, my first thought is of people who look different from me. These are the people who are “traditionally underrepresented minorities” in medical education, such as those of Black or African descent and those of Hispanic, Latino, or Spanish origin.

A disclaimer: I am a gay Asian of Chinese descent. However, most people tell me that I look “Hawaiian” or look like some exotic blend of non-Hispanic white. So, while white is a minority to me (globally-speaking), they are not a minority in medicine. And as a Chinese male, I am not a minority in the field of medicine. But most people don’t know (or care) that I am gay.

The AAMC website contains many tidbits of interest. In the US (data from 2011), the number of practicing physicians is approximately 816,000 of whom 68.5% are non-Hispanic white, 19.0% are non-Hispanic Asian, 5.8% are Hispanic, 4.9% are non-Hispanic Black, and 1.8% are “Other” (including multiracial) (3). Thus, the potential pool of clinical faculty who are persons of color is very small. Those who enter academic medicine are highly recruited to help “diversify” the faculty at all medical schools. I will assert that these numbers are equally challenging among basic science faculty.

Faculty are not the only ones who need to be recruited. It is difficult to find medical students of color. Here is a brief summary of data from the AAMC website (4, 5, 6). For brevity, a few other categories are not included in the table. The “Applicant” category includes all prospective medical students who applied for MD medical schools. The “Matriculants” are those who were accepted and entered into medical school that year (from the Applicant pool). The “Total Enrollment” represents the total number of students enrolled in MD medical schools (all years) in each category.

MedStudentData

With a class of 183 students at Einstein, it would be difficult, if not impossible, to create a population of students with proportions that look like the community around us (the Bronx) with the pool of students that are in the mix.

So, why is it an issue that medical educators need to address? After all, many of us do not participate in the decision to accept medical students.

First and foremost, many of us do not pay attention to this issue. Of my many colleagues in the basic science professoriate, most pay attention to the status of their research, graduate students, and the material they need to “teach” to medical students. However, many do not think about diversity issues. And we ought to be. I wonder how many of our faculty talk about how race and other diversity affect the sciences we teach (and do). How many are actively engaged in recruiting and developing basic science faculty who are persons of color? How many of us think about issues that would help our students confront diversity (colleagues and patients) when they go to their clinics?

This is an obligation not only of basic science faculty, but also of our clinical faculty. And how do they handle these issues?

Secondly, we know from numerous studies that many potential students of color are discouraged from medical careers for a number of reasons. Most are told they “cannot make it” and should not set themselves up for failure. This abominable practice is meant well, but flies in the face of logic and reason.

Why do people think people of color cannot make it?

We know it isn’t intelligence. Traditionally underrepresented minorities in medicine demonstrably are as capable, smart, and intelligent as any other student. All I need to do is look around me here at Einstein and at my previous schools and see that skin color has nothing to do with the ability to achieve and excel in medical school.

So, what does affect how well these students do?

I believe (don’t have data, but this is my perception based on the students I have taught over the years) that there are two major barriers for success for many of our underrepresented minority students: language and culture.

Many of the students that I have had who are unrepresented minorities have difficulty with English as used in medical school. This is a generalization and certainly does not apply to everyone. However, regardless the color of the skin or any other status, the ability to comprehend and master material in technical, medical English is critical to success in medical school.

This is true for two reasons. First, there is a tremendous amount of information that is provided to the student in a short amount of time. There is no time in a traditional curriculum to translate the information from the format in which it was presented into a more comprehensive form. Second, the English used in medical school is complex. It is a form of jargon that has a large number of unfamiliar vocabulary terms and concepts. These two facts alone make medical school challenging. To add another dimension of needing to learn the English context multiplies the difficulty that some students face.

Compounding the issue of English that is used differently, there is a cultural issue. AAMC data of matriculating medical students show that approximately half of all medical students come from families in the top quintile of income in the United States (7). Moreover, parents of Black and Hispanic medical students have less college education and fewer graduate degrees than White and Asian students (8).

Taken together, this means that the Black and Hispanic students who do make it into medical school generally come from less affluent and less educated family backgrounds. My experience is that this means that many of these students have a different mindset vis-à-vis what expectations they have of achievement and what it takes to support themselves through college. The bar for achievement is more often survival and not necessarily success.

I believe that there is something to this “learning by osmosis” concept (or perhaps immersion learning). That is, being around a more English-oriented and more highly educated environment gives persons who grow up in these circumstances an advantage when placed in an environment where high level of English capability is expected. The data would indicate that many Black and Hispanic students would not have grown up in these types of environment.

In conclusion, I assert that underrepresented minorities experience an exacerbation of the cultural and language gaps.

So, what can we – as medical educators – do?

We must recognize that slow or poor performance in the traditional lecture/lab/exam formats does not mean that the individual is less capable, less intelligent, or less eager to accomplish their career and educational goals. Rather, we must provide the supportive educational systems that will enable students to become successful. We do not need remedial programs; we need programs that enable students to break down the language and cultural barriers to success. No remediation is needed; students are intelligent and capable enough on their own. What they need is the opportunity to succeed.

Medical education needs to be based on educational competencies that students are expected to meet. Students need to be given the opportunity to follow a developmental pathway that is clearly defined where they can demonstrate achievement along the way. Medicine is dependent on having and finding knowledge and the art of being able to use that knowledge. What we need to provide as medical educators are programs that promote educational opportunities and encourage students to excel. It is not the role of medical educators to serve as gatekeepers to the profession. Students need to succeed or fail based on their ability to meet the educational milestones to fulfill the defined competencies.

It is our role as medical educators to help our schools achieve diversity goals. It is also our role as medical educators to give students the opportunity to succeed. And this has to be a cultural norm in medical education.

I have further thoughts about biases and competency education, but I will wait for another day, another time to reflect on those topics.

(1) http://einstein.yu.edu/about/history.asp
(2) http://quickfacts.census.gov/qfd/states/36/36005.html
(3) Table 2 of Section IV http://aamcdiversityfactsandfigures.org/section-iv-additional-diversity-data/ in the Diversity in the Physician Workforce: Facts and Figures 2014.
(4) Table 8: Applicants to U.S. Medical Schools. https://www.aamc.org/download/321472/data/factstable8.pdf
(5) Table 9: Matriculants to U.S. Medical Schools. https://www.aamc.org/download/321474/data/factstable9.pdf
(6) Table 28: Total U.S. Medical School Enrollment https://www.aamc.org/download/321534/data/factstable28.pdf
(7) https://www.aamc.org/download/102338/data/aibvol8no1.pdf
(8) https://www.aamc.org/download/142770/data/aibvol9_no10.pdf

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

 

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