Long-term Outcomes of Geriatric Medicine Teaching Strategies: Comparing no Content, Traditional Lecture, and Flipped Classroom 2 Years Postintervention

Abstract

Background

The long-term effects of use of the flipped classroom to teach geriatric medicine are still underexplored.

Objective

To investigate whether different educational interventions on geriatrics (i.e., flipped classrooms—FL and traditional lectures—TR) could have an influence on long-term attitudes and stereotypes among medical students compared to not having such exposure (control—CG) after 2 years of follow-up.

Method

An intervention study was conducted during the third year of medical school training. Two different educational strategies (FL and TR) were incorporated into a course of geriatrics. Students were evaluated at baseline, postintervention, and after 2 years of follow-up concerning their attitudes toward older persons (Maxwell–Sullivan, UCLA geriatric attitudes), empathy (Maxwell–Sullivan), knowledge and stereotypes (Palmore Facts on Aging), and self-reported opinions on older adults.

Results

A total of 216 medical students were included (68 CG, 72 TR, and 76 FL). At the 2-year follow-up, the FL had better scores than the TR on the Palmore Facts on Aging (d = 0.42); the FL had better scores than the control group for the Maxwell–Sullivan Attitudes (d = 0.40); and both the FL and TR had better scores for the Palmore Facts on Aging (d = 1.56 to 1.75) and the Likert items “preparedness” (d = 1.10 to 1.19), “knowledge” (d = 1.08 to 1.20), and “prescribing” (d = 0.33 to 0.40) compared to the CG.

Conclusions

Teaching geriatric medicine could impact the long-term outcomes of medical students and the way this teaching is delivered can influence students’ learning.

Introduction

The world is rapidly aging, and it is expected that at least 22% of the global population will be over 60 years old, posing important challenges to health care systems and future workforces due to the number of chronic conditions, inappropriate medications, functional problems, and inequalities that this age group usually faces [1]. In this context, future health care professionals will need the knowledge, attitudes, and skills to treat these older individuals, to provide multidimensional and comprehensive care [2]. Therefore, medical training on this topic is urgently needed.

Despite the growing statistics, few medical students seem to be interested in treating and caring for older persons or consider a career in geriatric medicine [3, 4]. Among several factors that may impact this shortage of geriatricians, previous experiences (e.g., experiences with geriatrics teaching and educational strategies) were among the most important [4]. Therefore, using innovative methods of teaching may increase the interest of students in the field of geriatrics.

Geriatric medicine is a field in which educational strategies play a pivotal role. Several education initiatives were developed by geriatricians, such as the aging game, escape rooms, role plays, and hospital scenarios [5, 6]. Likewise, this field has substantial geriatrics educational collections in the MedEdPORTAL, which was created to foster discussion and provide educational material to those interested in teaching.

Among several active teaching strategies, the flipped classroom is an opportunity to focus on applying knowledge inside the classroom, reversing the lecture-homework elements and leaving the theoretical traditional lecture to the preclass online environment [7]. This active learning method relies on the student-centered learning theories [8], including activities with low Bloom’s taxonomy (i.e., prerecorded video lectures, reading materials) out of the class, while inserting high Bloom’s taxonomy activities (i.e., application of knowledge and practical activities) inside the class [9, 10]. Previous meta-analyses have indeed shown moderate effect sizes favoring the effectiveness of the flipped classroom in health care settings and schools [7, 11]. Due to its interactive nature and its in-class practical activities, this strategy of teaching could be particularly suited for the geriatric education, fostering students’ collaboration (a key issue for the interprofessional treatment of older adults), making students to experience aging limitations, improving attitudes toward older adults and motivating students to handle the challenges and complexities of older individuals.

However, few studies have assessed the results of flipping the classroom in the teaching of geriatrics. Previous studies have used WeChat to flip the classroom with Chinese medical students [12], flipped the Acute Care for Elders teaching sessions for US internal medicine residents [13], and flipped the entire geriatrics course for Brazilian medical students [14]. This latter reference [14] was a publication from our research group investigating the short-term results of flipping classrooms, which showed promising results for significantly better knowledge, attitudes, and satisfaction when compared to traditional teaching.

Nevertheless, these studies have assessed only immediate short-term results of flipping classrooms. Understanding if long-term results also could be achieved by this teaching strategy may allow educators to promote better interactive sessions aiming to minimize the loss of learning and promote a greater interest among students.

Therefore, the present study aims to investigate whether different geriatric interventions (i.e., flipped classroom—FL and traditional lectures—TR) could have an influence on long-term attitudes and stereotypes among medical students compared to not having such exposure (control—CG) after 2 years of follow-up. For this purpose, we are going to investigate new data from the original flipped classroom study [14], but now assessing the long-term outcomes after 2 years of follow-up.

Materials and Methods

Design, Setting, and Participants

This was an intervention educational study (pretest and posttest with a nonrandomized control group) carried out at a Brazilian public medical school between 2014 and 2018. The study was approved by the University Hospital’s Ethics Research Committee, and students signed a consent form. As previously described, this study uses data from a previous published article that assessed the short-term outcomes of these strategies [14]. In this new data analysis, we are investigating the 2-year follow-up outcomes for these students, showing if these interventions could be effective even after longer periods of time.

To be included, students had to be officially registered in the medical course, over 18 years old, and attend the geriatrics course activities (in the case of the flipped classroom or traditional groups) or be in the third year of medical school (in the case of the control group). Students not found at the 2-year assessment were excluded from the analysis.

The medical training in Brazil lasts 6 years, which are divided into three phases: preclinical (first 2 years, basic sciences), clinical (third and fourth years, medical specialties), and clerkship (final 2 years). This study took place in the third year of medical school in the clinical phase.

Procedures

Students were approached during class activities in the following moments: at baseline, i.e., before the geriatrics course in the third year (in the case of FL and TR); postintervention (after 16 weeks); and after 2 years of follow-up (before entering the clerkship in the fifth year of medical training).

Instruments

The following instruments were collected at these three timepoints:

• Sociodemographic data: age and sex

• UCLA Geriatrics Attitudes scale [15]: a 14-item questionnaire validated in Portuguese [16] used to assess attitudes toward older persons. In this instrument, higher scores indicate better attitudes.

• Palmore Facts on Aging Quiz [17]: a 25-item questionnaire validated in Portuguese [16] used to assess general knowledge and stereotypes toward older persons [18]. In this instrument, higher scores indicate better knowledge and lower stereotypes.

• Modified Maxwell–Sullivan Attitudes and Empathy Scale [19]: an 11-item questionnaire validated in Portuguese [16] used to evaluate attitudes and empathy toward older persons. In this instrument, scores are reversed, i.e., lower scores indicate better attitude and empathy.

• Self-reported Likert opinions developed for the present study, including the following: “I feel prepared to take care of an older person,” “I have knowledge on geriatrics,” “I should be careful prescribing to an older person,” and “Older people are multidimensional (bio–psycho–social–spiritual) beings.” Possible responses range from 0 (“I do not agree at all”) to 10 (“I completely agree”).

Study intervention groups (theoretical classes)

We investigated three different classes of students in consecutive semesters and all students were in the third year of medical school. In our medical school, students are admitted in the beginning or in the middle of the year, resulting in two classes per year. Therefore, each class entered the third year separated from the others. The first class was not exposed to any content of geriatrics (control group), the second class was exposed to traditional teaching, and the third class was exposed to the flipped classroom. A mandatory course “Geriatrics and Gerontology” was inserted into the third year of medical training and met for 4 h (with practical and theoretical classes) per week over 16 weeks, for a total of 64 h. The instructors and professors for the course were similar for both the traditional and flipped classroom strategies.

• Control group (CG): medical students who did not receive the mandatory course “Geriatrics and Gerontology” in the third year and who did not have any formal geriatrics teaching.

• Traditional group (TR): Professors carried out lectures about the proposed theme using multimedia resources and a whiteboard. Students had not previously had any exposure to the content and learned it in the classroom, being able to ask professors questions when they wished. A complementary bibliography (available online) was offered to students. Students also had access to nonmandatory online homework problems to apply their knowledge.

• Flipped classroom (FL): students were exposed to online lectures, previously recorded by the course professors (short, 15–20 min in duration). The same complementary bibliography offered to the traditional group also was offered to this group. During in-person activities, students were exposed to interactive activities conducted by the same TR professors to apply their knowledge. The educational activities of the FL are reported elsewhere in detail [6]. In brief, it included interactive strategies such as gamification, jigsaw teaching, and team-based learning and case discussions. The goal of this strategy was to work with the previous knowledge of medical students obtained through online videos and reading and to make them discuss and interact with other students and apply their knowledge in class.

Practical Classes

The practical classes were similar for both the FL and TR groups and they took place in the same timeframe of the didactics. Some examples of the practical activities were visiting a nursing home, applying a comprehensive geriatric assessment (CGA) in older persons from the community, an interprofessional fair, walking devices, and experiencing aging. The practical educational activities of the FL also were reported elsewhere in detail [6].

Statistical Analysis

Descriptive analyses were carried out using absolute numbers, percentages, means, and standard deviations.

For the inferential analyses, mixed ANOVAs were then carried out to evaluate the effects of group (FL, TR, and CG), time (baseline, postintervention, and after 2 years), and the interaction group × time on the following outcomes: UCLA Attitude scale, Palmore Facts on Aging Quiz, Modified Maxwell–Sullivan Attitudes Scale, Modified Maxwell–Sullivan Empathy Scale, and the Likert items “I feel prepared to take care of an older person,” “I have knowledge on geriatrics,” “I should be careful prescribing to an older person,” and “Older people are multidimensional (bio–psycho–social–spiritual) beings.” For the comparison among groups, post hoc tests were carried out using Bonferroni.

All analyses were carried out using R version 4.2.1, and p values < 0.05 were considered significant.

Results

As reported in the “Materials and Methods” section, data from a previous study [14] was used in this paper. However, it is important to highlight that there are slight changes between the short-term outcomes of our present paper as compared to that 2018 paper. The reason for these slight differences is the fact that there are some losses of follow-up after 2 years [14]. For the present long-term analyses, 248 medical students were invited to participate in this study, 82 from the control group class (CG; no intervention), 83 from the traditional class group (TR), and 83 from the flipped classroom group (FL). At baseline, 5 students from the CG were absent, totaling 77 students for the CG, with no absences in the other groups. After 2 years of follow-up, the final sample included in the present study consisted of 216 students (68 CG, 72 TR, and 76 FL). The reasons for exclusion were the absence of students during the follow-up data collection. The participants had a mean age of 21.6 years (SD, 2.34), and most participants were women (n = 132, 61.1%). The flow diagram for the study is available in Fig. 1.

Fig. 1.

Flow diagram of participants

Concerning the baseline characteristics of the sample, no significant differences were observed for age, gender, UCLA Attitudes, Palmore Facts on Aging, Maxwell–Sullivan Attitudes, “I feel prepared to take care of an older person,” “I should be careful prescribing to an older person,” and “Older people are multidimensional (bio–psycho–social–spiritual) beings.” We identified differences favoring the control group as compared to the others, on Maxwell–Sullivan Empathy and “I have knowledge on geriatrics” (Table 1).

Table 1.

Comparison among the flipped classroom, traditional teaching, and no intervention (control) in the baseline (n = 216)

	TR (n = 72)	CG (n = 68)	FL (n = 76)	p
	n (%)	n (%)	n (%)
Sex (female)	47 (65.3%)	44 (64.7%)	41 (53.9%)	0.284
Age (< 24 years)	61 (84.7%)	56 (82.4%)	69 (90.8%)	0.299
	Mean (SD)	Mean (SD)	Mean (SD)	p
Palmore Facts on Aging	11.3 (2.71)	10.5 (2.34)	11.2 (2.54)	0.282
UCLA Attitudes	52.2 (4.46)	53.0 (4.41)	51.9 (4.79)	0.806
Maxwell–Sullivan Empathy*	5.7 (2.15)	4.76 (1.28)	5.1 (1.74)	0.002
Maxwell–Sullivan Attitudes*	16.2 (3.00)	15.0 (3.14)	15.5 (3.22)	0.060
“I feel prepared to take care of an older person”	3.31 (2.28)	3.77 (2.41)	2.99 (2.26)	0.650
“I have knowledge on geriatrics”	2.07 (2.03)	2.86 (2.32)	1.53 (1.76)	0.016
“I should be careful prescribing to an older person”	9.80 (0.55)	9.87 (0.46)	9.70 (0.65)	0.406
“Older people are multidimensional (bio–psycho–social–spiritual) beings”	9.63 (0.90)	9.62 (1.42)	9.74 (0.68)	0.985

Baseline and postintervention data-points were obtained from data of our original study published in 2018 (Granero Lucchetti AL et al. Medical teacher. 2018;40(12):1248–56) with slight changes in the number of participants due to losses in the 2-year follow-up (see “Materials and Methods” section)

^*Inverted scores: lower values denote greater attitudes and empathy at baseline

Mixed repeated-measures ANOVAs were carried out for the different models as follows: (a) UCLA Attitudes: there were significant effects for time (F = 19.51, p < 0.001, ges = 0.030) and the interaction group × time (F = 5.20, p < 0.001, ges = 0.016); (b) Palmore Facts on Aging: there were significant effects for group (F = 102.65, p < 0.001, ges = 0.39), time (F = 261.76, p < 0.001, ges = 0.35), and the interaction group × time (F = 66.96, p < 0.001, ges = 0.22); (c) Maxwell–Sullivan Empathy: there were significant effects for time (F = 23.37, p < 0.001, ges = 0.036) and the interaction group × time (F = 5.94, p < 0.001, ges = 0.018); (d) Maxwell–Sullivan Attitudes: there were significant effects for time (F = 24.22, p < 0.001, ges = 0.039) and the interaction group × time (F = 7.87, p < 0.001, ges = 0.026); (e) “I feel prepared to take care of an older person”: there were significant effects for group (F = 31.925, p < 0.001, ges = 0.16), time (F = 305.16, p < 0.001, ges = 0.33), and the interaction group × time (F = 63.70, p < 0.001, ges = 0.17); (f) “I have knowledge on geriatrics”: there were significant effects for group (F = 48.66, p < 0.001, ges = 0.22), time (F = 514.32, p < 0.001, ges = 0.47), and the interaction group × time (F = 110.87, p < 0.001, ges = 0.28); (g) “I should be careful prescribing to an older person”: there were significant effects for time (F = 5.46, p = 0.007, ges = 0.012) and the interaction group × time (F = 4.25, p = 0.004, ges = 0.019); (h) “Older people are multidimensional (bio–psycho–social–spiritual) beings”: there were no significant differences among groups.

Post hoc comparisons between groups were carried out and are presented in Figs. 2 and 3. After the intervention, the FL had better scores than the TR for the Likert items “I feel prepared to take care of an older person” (Cohen’s d = 2.25) and “I have knowledge on geriatrics” (Cohen’s d = 2.86). Both the FL and TR had better scores than the CG for UCLA Attitudes (Cohen’s d = 0.38 to 0.57), Palmore Facts on Aging (Cohen’s d = 2.74 to 3.31), Maxwell–Sullivan Attitudes (Cohen’s d = 0.45 to 0.46), “I feel prepared to take care of an older person” (Cohen’s d = 1.82 to 2.25), and “I have knowledge on geriatrics” (Cohen’s d = 1.61 to 1.76).

Fig. 2.

Comparison among the flipped classroom, traditional teaching, and no intervention (control) across time on the UCLA Geriatrics Attitudes scale, Palmore Facts on Aging Quiz, Modified Maxwell–Sullivan Attitudes Scale, and Modified Maxwell–Sullivan Empathy Scale. Baseline and postintervention data-points were obtained from data of our original study published in 2018 (Granero Lucchetti AL et al. Medical teacher. 2018;40(12):1248–56) with slight changes in the number of participants due to losses in the 2-year follow-up (see “Materials and Methods” section). The new analyses here relied on the 2-year follow-up outcomes. Legend: Traditional: Traditional teaching, Control: Control Group (no content) and Flipped: Fipped Classroom teaching

Fig. 3.

Comparison among the flipped classroom, traditional teaching, and no intervention (control) across time on the following Likert items: “I feel prepared to take care of an older person,” “I have knowledge on geriatrics,” “I should be careful prescribing to an older person,” and “Older people are multidimensional (bio–psycho–social–spiritual) beings.” Baseline and postintervention data-points were obtained from data of our original study published in 2018 (Granero Lucchetti AL et al. Medical teacher. 2018;40(12):1248–56) with slight changes in the number of participants due to losses in the 2-year follow-up (see “Materials and Methods” section). The new analyses here relied on the 2-year follow-up outcomes. Legend: Traditional: Traditional teaching, Control: Control Group (no content) and Flipped: Fipped Classroom teaching

After 2 years of follow-up, the FL had better scores than the TR for the Palmore Facts on Aging (Cohen’s d = 0.42); the FL had better scores than the control group for the Maxwell–Sullivan Attitudes (Cohen’s d = 0.40); and both the FL and TR had better scores for the Palmore Facts on Aging (Cohen’s d = 1.56 to 1.75) and the Likert items “I feel prepared to take care of an older person” (Cohen’s d = 1.10 to 1.19), “I have knowledge on geriatrics” (Cohen’s d = 1.08 to 1.20), and “I should be careful prescribing to an older person” (Cohen’s d = 0.33 to 0.40) compared to the CG.

Discussion

The present study found that more interactive teaching strategies, such as the flipped classroom, resulted in better scores compared to traditional teaching in relation to the Palmore Facts on Aging scale, an instrument assessing knowledge and stereotypes on aging. Likewise, the flipped classroom, but not traditional teaching, was associated with better attitudes in relation to the control group (not having the intervention) after 2 years of follow-up. Finally, self-rated items such as preparedness, knowledge, and being careful in prescribing all had greater scores for both the FL and TR in relation to the CG after 2 years.

Our first finding revealed that, even after 2 years of follow-up, aspects such as increased knowledge and reduced stereotypes were maintained significantly by both interventions in relation to the control group. This reveals that even a short geriatric intervention (64 h) can retain the learning of students in the long term. This is a promising finding since, according to the previous literature, there is a 50 to 70% loss of knowledge after 1 to 4 years of follow-up [20–22].

The main reason for learning declines is lack of exposure to the content [23]. In the case of our medical students, geriatrics teaching is provided in the third year of medical training and, after that, only in the clerkship (fifth to sixth years). Therefore, in such scenarios, teaching strategies should be captivating and have good clinical implications, aiming to reduce lack of interest and promote the retention of content.

Another important finding of this study was that the scores of Palmore Facts on Aging were different between the FL and TR after 2 years of follow-up. Palmore is a measure of both knowledge and stereotypes toward aging and is one the most used and validated instruments for geriatrics teaching [18]. Indeed, reducing ageism and stereotypes is one of the goals of geriatrics teaching [2], being associated with better views toward older adults [24, 25], more knowledge on aging, more comfort treating older adults, and more willingness to consider a career in geriatrics [26]. Previous studies have found that, in the same direction, the FL group was associated with better attitudes on the Maxwell–Sullivan scale in the long term, indicating that active learning, but not TR, was able to retain positive attitudes toward older adults.

Previous studies have already found favorable effects of active learning on academic outcomes [27, 28]. A previous meta-analysis across different disciplines found that active learning increases examination performance, raising average grades by half and decreasing failure by 55% compared to traditional lecturing [27]. The use of active learning also seems to change frontoparietal brain activity compared to passive learning, possibly related to the formation and reactivation of semantic representations [28].

There are several ways of carrying out active learning, and strategies such as team-based learning, case-based learning, jigsaw, and the flipped classroom have already been used in geriatrics teaching [14, 28–30].

Specifically, regarding the flipped classroom, there is evidence of its effectiveness across different disciplines in health care. Two meta-analyses found a significant effect in favor of the flipped classroom over traditional lectures, with SMD = 0.33 and 28 studies included in the first [7] and SMD = 0.46 and 46 studies included in the second [11]. However, studies assessing the long-term effects of flipping the classroom are scarce. A previous study [31] found that the grades after 18 months of completion of a physiology course were greater for those medical students who received the flipped classroom as compared to those in the traditional classroom. Another study using flipped classroom to teach anatomy for medical students [10] has also found long-term effects of better knowledge after 2 months of follow-up as compared to traditional teaching. Likewise, a study including clerkship medical students [32] found that flipped classroom was superior to online-only instruction for clinical skills after 1 year of follow-up. These studies are in line with our findings, showing that flipped classroom could result in better levels of educational outcomes after months or years, being superior to traditional methods.

In the field of geriatrics, studies are even scarcer. A study carried out in 15 internal medicine residents found that a flipped classroom curriculum for competencies was able to significantly improve self-efficacy ratings [13]. Among medical students, the previous study from our group [14] showed that students receiving geriatrics content through the flipped classroom demonstrated greater gains in knowledge, improved attitudes, felt more prepared to treat older people, believed they had more knowledge, were more satisfied, and evaluated the discipline’s format better in comparison to the traditional group in the short-term follow-up. Our present findings have provided further evidence on this topic, showing that the flipped classroom can have even a long-term effect, reducing stereotypes and improving knowledge through the Palmore Facts on Aging Quiz, compared to the traditional way of teaching.

Despite these promising findings, some limitations should be considered. First, only a single medical school from Brazil was included. It is possible that the results would be different if other medical schools and countries were included. Second, this was a quasi-experimental study, and for this reason, no randomization was performed, and this may have resulted in a selection bias with misbalance groups. In our study, the only two baseline differences (empathy and self-opinion of knowledge) favored the control group, which could have minimized such problems. The reasons for not carrying out a randomized trial were due to the protected status of the student population and the ethical limitations of having three different strategies in the same class of students which could have an impact on grades and performance. For this reason, entire classes were selected for having each intervention [33]. Third, self-reported instruments were used, and it is not possible to verify if the same outcomes would be replicated in clinical practice. Finally, our medical school has an important gap in the content of geriatrics from the third year to the fifth year. Longitudinal insertions of geriatric content would reduce the decline in learning.

Despite these limitations, several clinical and educational implications can be drawn from our findings. For policymakers, as previously discussed, the field of geriatrics is experiencing a reduced interest from medical students [3, 4] and, in this context, interactive activities may enhance the motivation and curiosity of students by the geriatrician career, promoting not only knowledge, but also better attitudes toward older adults. For educators, the implementation of flipped classroom is feasible and relies on the incorporation of short and stimulating online activities before the class (recorded lectures, reading materials, quizzes). This allows students to obtain the knowledge that they will use for in-class activities such as simulation scenarios, practice of clinical skills, and patients’ encounters and case discussions [6]. It is important to note that offering high-level taxonomy in-class activities is one of the most important components of flipped classroom, since its objective is to move lecture away from the lecture hall [34]. To be successful, students must be aware of this method and studying time should be provided. In addition, teachers should be trained to act as active moderators, as guides or mentors, and to understand how student-centered approaches should be delivered [35].

In conclusion, teaching geriatric medicine could impact the long-term outcomes of medical students. The way this teaching is delivered can influence students’ learning, since there were differences between active and traditional strategies after 2 years of follow-up. These results may serve to educate educators in the field of geriatrics to promote more dynamic and applied content aiming to improve academic outcomes and reduce stereotypes toward older persons among medical students. Providing dynamic and interactive models of teaching could awaken the interest of students and retain some important aspects of geriatrics teaching.

Author Contribution

GL and ALGL contributed equally to study concept and design, acquisition of data and/or subjects, analysis, and interpretation of data and drafting and revision of the manuscript.

Funding

This study was funded by a research grant from FAMEPIG (Fundação de Amparo à Pesquisa do Estado de Minas Gerais), Brazil, under grant number PPM-00645–18.

Data Availability

The data are available upon reasonable request from the authors.

Declarations

Ethics Approval and Consent

The study was approved by the University Hospital’s Ethics Research Committee, and students signed a consent form.

Conflict of Interest

The authors declare no competing interests.