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. 2020 Aug 31;93(3):411–417.

The Feasibility of Incorporating a Flipped Classroom Model in an Anesthesia Residency Curriculum—Pilot Study

Viji Kurup 1,*, Garrett Sendlewski 1
PMCID: PMC7448396  PMID: 32874146

Abstract

Background: Medical education is evolving to incorporate learner-centered strategies which encourage student engagement. Educators need to ensure that meaningful education occurs within limited interaction time between teachers and trainees. The Flipped Classroom (FC) model combines the use of both online and face-to-face interaction. Studies describing the process and resource utilization in anesthesia residency programs are limited. Methods: After Institutional Review Board (IRB) exemption, a qualitative study to assess the feasibility of introducing an FC model in the anesthesia residency didactic curriculum was conducted. The Post Graduate Year 2 (PGY2) anesthesia resident didactic sessions were modified to include one session a month using the FC format with the other three sessions presented using traditional PowerPoint lecture format at a tertiary academic medical center. Post-session surveys were administered to both learners and teachers. Survey data were analyzed using Qualtrics® software. Survey data included perceptions of both learners and teachers regarding quality of learning and engagement in the new format. Results: Nineteen residents and 10 faculty participated in 10 sessions over the span of 10 months. A total of 153 resident responses and 8 faculty responses were submitted voluntarily. In our study, a majority of residents indicated they preferred the FC format. They also indicated they enjoyed working in groups. All the participating faculty felt that student interaction and student learning were higher in these sessions. Conclusions: Residency programs need to adopt evidence-based solutions to problems arising in medical education. We present our experiences in finding a solution to make didactic sessions more engaging. Our initial assessment shows that it is feasible to introduce the FC model into an existing curriculum in an anesthesia residency program and both residents and faculty felt that the format enhanced learning and interaction in class.

Keywords: Flipped Classroom, Adult learning, Media in education, Post-graduate education, teaching/learning strategies

Introduction

Medical education has made significant advances since Abraham Flexner submitted his report in 1910 regarding the state of medical education at that time [1]. Educators in anesthesia residency programs still face significant challenges, especially regarding the format for didactic education. Studies have also demonstrated that residents today have less time available for educational activities [2,3]. Our anesthesia residency program was in the process of rethinking curriculum design in response to resident feedback that didactic sessions were not engaging. In an effort to make sure we use efficient systems of knowledge delivery to promote resident learning in the initial years of their training, we adopted an evidence-based approach to changing the curriculum. The authors had previously proposed that the Flipped Classroom (FC) model might be one solution to the educational dilemma [4]. The FC model is an emerging approach that combines online content delivery with interactive face-to-face sessions between faculty and students [5-7]. The word “flip” comes from the inversion of the traditional model of teaching. Traditionally, students come to class and listen to a teacher-led presentation focused on information about a topic (usually lecture-based) and then work on their own to interpret this information in the clinical setting. In the FC model, the basic information regarding the topic is given to students before class and is integral to their participation in the class. The “in-class” time can then be devoted to clinical application of the concepts using active learning techniques. Although this method has gained acceptance in undergraduate education as well as medical schools [8,9], it is beginning to gain visibility in Graduate Medical Education and anesthesia residencies [10,11]. In this project we set out to assess the process and value of introducing the model in an anesthesia residency program while evaluating acceptability to both learners and teachers.

Materials and Methods

Evidence based approach: We performed a literature review in learning methodologies for best practices for education. The focus was on looking at optimal ways to use “Blended Learning” which is a combination of online and face-to-face sessions to enhance learning. The key points from this review that have been distilled are as follows [12]:

• With regard to blended learning, where online and face-to-face instruction are combined, the best results are obtained when both online and face-to-face learning are used in a curriculum. Either of them alone do not result in efficient learning [13].

• Recent studies have shown that online materials work best when they are used to convey concepts requiring lower order cognitive skills as described in Bloom’s taxonomy [14] (recall of information, comprehension) [15] and face-to-face discussions with expert faculty using active learning techniques to facilitate the best learning gains for concepts involving higher order cognitive skills (analyzing patterns, synthesizing information, and evaluating outcomes).

Creating awareness regarding the model: To create awareness in the department, a grand rounds focused on the FC model was conducted. Faculty volunteers willing to incorporate the method were solicited and individual training and instruction was provided along with audio-visual resources.

Implementation of the project: We obtained Institutional Review Board (IRB) approval for the project. The research question was: What is the impact of a FC curriculum in the Department of Anesthesiology at Yale on residents and faculty?

Curriculum: The curriculum of the Post Graduate Year 2 (PGY2) (Clinical Anesthesia 1 year, CA1) residents was designed at the beginning of the academic year to incorporate one didactic session based on the FC format each month. The didactic sessions are scheduled for 1 hour each week and the first week of each month had a session based on the FC format whereas the rest of the 3 weeks were in the traditional format predominantly composed of PowerPoint presentation lectures. The participating faculty submitted goals and objectives for their sessions as they did for traditional lecture-based sessions. They then prepared an outline of material to be covered in the podcast and material that would be covered in the face-to-face session. In order to ensure consistency and quality of the podcasts, they were developed with the assistance of an Associate at the Media Lab in our department (GS). This individual was well versed with graphic design and assisted the faculty with converting their presentations into effective podcasts. To create the podcasts, the faculty could record their slides with voiceover, or create de novo animations of the concepts they wished to present. Assistance was provided, when necessary for choosing content as well as audio-visual assistance to prepare the podcasts (VK, GS). The podcasts created were hosted by the lecture capture system used by our university, Echo 360®. Using editing programs Adobe After Effects®, Adobe Photoshop®, and Adobe Premiere®, it took between 2 hours to 12 hours of work for the media lab associate depending on the amount of figures/animations needed per session. The podcasts were made available to the residents at least 2 weeks before their sessions with reminders a week before and a day before.

Sample: Ten faculty volunteered to use the new method for their sessions for CA1 class.

Data collection: It was possible to monitor number of views for the videos that were accessed ahead of the didactic sessions, but the software did not allow us to monitor views accessed from mobile devices such as iPads or smart phones. As a result, the data were not used to track viewing, and the self-reported survey data were used to determine whether the residents watched the videos before the session. A survey was distributed to all students and faculty who took part in the sessions (Appendix A). A total of 10 sessions were conducted over 10 months. There are 19 residents in the class, however not all residents are able to attend all the sessions due to clinical activities or other commitments. The total number of attendees for the 10 sessions was 153. Every resident who attended the sessions completed the resident survey anonymously. The faculty completed the faculty survey anonymously. The data were collated using the web-based survey tool, Qualtrics® which is licensed for institutional use.

The key steps in implementation are summarized in Figure 1.

Figure 1.

Figure 1

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Overview of the process of implementation of FC model in a residency.

Results

A total of 153 responses were collected from students who attended the FC sessions. Every resident who attended the sessions completed the survey. The survey contained questions regarding their perception of learning in the FC format compared to the traditional lecture format. The results from the survey to the learning attitudes questionnaire is given in Figure 2. The majority of residents used their personal computer or laptop (79%) to view the podcasts followed by mobile tablet use (16%). There was only one student out of the 153 responses who responded that they had not watched the pre-work video. However, the subjective perception even for that participant was that they learned more from in-class work in the FC format than in the traditional lecture format.

Figure 2.

Figure 2

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Responses of learners to questionnaire (n=153). Participants were asked to score the statements on a 5 point scale from 1 (strongly disagree) to 5 (strongly agree).

There were some open-ended comments from the residents as well. Some of the comments were:

• “Great, because the material is reinforced. I love this”

• “The acid-base lecture worked very well. Not all topics may work well in this format”

• “For those who can’t make the lecture or those that can’t stay till the end please send out the answers (to questions discussed) after the lecture for residents to review and study”

• “Early in the year, I think Traditional is better because we don’t have a lot of knowledge and experience”

The teacher feedback survey had five questions to assess teacher perception of student engagement and learning as well as free text for comments and suggestions (Appendix A).

All the teachers felt that student engagement and student learning was higher in the FC format than in traditional lectures that they had given. Fifty percent of the teachers felt that there was more preparatory work for the FC format than for the traditional lecture. Also, 80% of teachers stated that they would prefer the FC format for future sessions. When asked if they (i.e. the teacher) were learning a new concept, what format would they prefer, 100% of the teachers favored the FC format. Some of the comments from the teachers’ survey was very revealing.

• “It was surprising to see that residents were so well prepared to discuss the topics and one resident had brought a book related to the topic to class.”

• “I never want to give a traditional lecture again–this was awesome.”

Discussion

Changes to the educational curriculum should be made in response to a defined need and the solution should be implemented thoughtfully using evidence-based models. We elaborate here our response to a defined “need” by our learners to make the didactic sessions more engaging. We identified a model that could help, created awareness regarding the model, gave resources to the learners and teachers to be able to apply the model to their teaching and evaluated acceptability of the model to the learners. The FC is a comparatively new technique in medical education. It combines a few well-known principles such as “pre-exposure” of study material and “interactive classroom work” in a single model. In their editorial, Huffmeyer et al. herald it as one of the teaching techniques of the future [16]. It has been used in a few disciplines such as surgery clerkship where there was improvement in learner satisfaction and pre and post test scores [17]. A study by Graham et al. randomized Internal Medicine residents to three 2-hour sessions on cardiovascular risk in the traditional or FC format and found that learner scores on knowledge test post intervention and 3-6 months post intervention were significantly better in the FC group [18]. Rashid et al. reported a possible curriculum for point of care ultrasound (POCUS) using the FC model for anesthesia residency programs [19].

In our study, we found that overall, both residents and faculty were receptive to this new model of instruction. However, there were a number of challenges that we identified with implementing the FC classroom. First of all, it takes commitment and motivation on the part of the students to complete the pre-session work for the didactic session. Therefore, the design of the material for the pre-session work should also be tailored to the subsequent discussion during class, and as such, the faculty who are involved in the class discussions should be closely involved in the production of the pre-session material, whether they are podcasts, videos, or handouts. If the material includes podcasts or videos, focus group discussions with our students in the past have indicated that these should be no longer than 20 mins to improve their compliance with completion. There have also been concerns that the assignments significantly increased the time students had to spend working outside of class. In our study learners felt that they spent more time on pre-session work in this format than in traditional lecture sessions. This is consistent with student responses in other studies [20]. A systematic review on the topic which included 46 articles in the final analysis found inconsistent effects of FC with learning [21]. It is also possible that prior experience and familiarity with the technology may affect learning gains although this still needs further study [22]. In terms of faculty workload, 50% of the faculty felt that there was an increase in workload, especially in the first attempt of the production of the podcasts or videos. To maximize faculty compliance, they will need some technical help and software to produce the material. However, since the podcasts discuss basic material, they may also be used for subsequent years with minimal modification. We plan on continuing use of the FC model with the intent to evaluate higher outcomes in the Kirkpatrick model focusing on whether the sessions lead to long term behavior change in specific topics [23].

We acknowledge there are limitations to this study. This was a qualitative research study designed to evaluate the impact of the FC model. We did not conduct a pre- and post-test to assess knowledge gains. The outcomes were subjective perceptions of the learners and teachers.

Although teachers have been using material to prime students before they arrive at the classroom for a very long time, the process has only now been studied and gained acceptance among both teachers and learners. Interestingly, it required the convergence of a number of trends for the process to be viewed as a feasible method of instruction in higher education. The advancement in technology and the “democratization of knowledge” that it created has made it easy for educators to create and use material in the public domain to prime their students with basic information. (There are a number of textbooks with podcasts associated with texts. There are also a number of podcasts on various topics created by individual teachers and posted in public domain that can be used). At the same time, there has been a paradigm shift in education, where the focus has shifted from whether “teaching is taking place” to whether “learning is taking place.” Added to this is the economic climate where departments are looking to methods where the teacher and student time is used most efficiently. The culmination of these trends has necessitated the development of novel and disruptive methods of instruction [24].

In an era where availability of information is pervasive, learning need not occur only within the institutional walls and in the presence of a teacher. The FC model can facilitate learning at any time and any place and allows faculty to use their skills and expertise in an effective and efficient manner. More studies are needed to assess the conditions under which this format can be best used.

Acknowledgments

The authors wish to thank the faculty and residents who took part in the project. The authors would also like to thank Dr. John Encandela, Associate Professor, Associate director for curriculum and educator assessment, and Dr. Roberta Hines, Professor of Anesthesiology at Department of Anesthesiology at Yale for their editorial guidance in the preparation of this manuscript.

Glossary

FC

Flipped Classroom

IRB

Institutional Review Board

PGY2

Post Graduate Year 2

CA1

Clinical Anesthesia 1 Year

Appendix A.

Author Contributions

VK: Conception and design; Administration; Writing; Review and Editing. GS: Data Collection and Analysis, Review and Editing.

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