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In order to meet students’ changing needs, educators are “flipping” the classroom and changing how they teach.

You might assume there are only so many ways to teach the coagulation cascade or the brachial plexus. But if you think today’s medical students are learning the way you did, you need schooling. Sitting in a crowded lecture hall to hear a professor and scribble notes, then heading home or to the library to memorize the material, will soon seem as archaic as overhead projectors.

Medical school class attendance is dropping as much as 70-80% in some classes, according to Dr. Charles Prober, Senior Associate Dean of Medical Education at Stanford University School of Medicine. In an age where everything can be recorded and played back on a portable device, students are eliminating what they consider the lowest-yield hours of their medical education: going to lectures.

In response to the new technology, and changes in student habits, medical schools are quickly implementing sweeping curriculum reform and “flipping the classroom.” It’s now assumed that students will absorb the basics on their own, at their convenience, using smartphones, tablets or web-based lectures and interactive learning modules. Then they come back to school to work out problems they’ve encountered or apply what they’ve learned.

While this is admittedly an attempt to bring students back to the classroom, it’s a classroom none of us would recognize. In this form of medical education, traditional lecture time is replaced with discussion of patient cases and application of basic principles to those cases.  Faculty in this model “would be able to actually teach, rather than merely make speeches,” Dr. Prober predicts. 

But even as students learn about evidence-based medicine, the flipped classroom model in medical education has little study data to back it up. A large federal review of secondary school and college education ( REF: PDF: http://www2.ed.gov/rschstat/eval/tech/evidence-based-practices/finalreport.pdfrecently showed a small but meaningful advantage to flipped classrooms, in terms of academic performance. But another study (REF: http://www.nber.org/papers/w16089found low-performing students do worse with online education, compared to traditional lectures.

Critics of flipped classrooms worry that struggling students, or those lacking motivation, will not be willing to come to class and admit their confusion about the source material in front of peers who’ve already grasped it. Proponents counter that the status quo – students struggling with the material quietly at home, alone and without help - is worse. And they note that historically, the flipped classroom was designed to engage students that were uninspired by traditional formats. 

It should be noted that most research involving the “flipped classroom” has examined the habits of high school and college students, rather than medical students, who tend to be high-achieving and motivated learners. In a 2012 commentary in the New England Journal of Medicine, Dr. Prober documents the Stanford experience (REF: http://www.nejm.org/doi/full/10.1056/NEJMp1202451 ): improved class attendance, course reviews, and test performance by students enrolled in interactive, problem-based lectures as opposed to the traditional “one mouth to many ears” format.

The same benefits may also be conferred upon continuing medical education, as more and more CME providers take advantage of digital learning techniques. The new learning modalities students are enjoying have made the process of CME more convenient for physicians of all ages. Podcasts and tablet-based online quizzes make CME and studying for recertification something you can work on during your downtime.

The Downsides to Digital

Most learners appreciate this new convenience, but whether it’s better for retention or practice is very much an open question. Critics of podcasts in medicine (REF Zanussi 2012 http://www.ncbi.nlm.nih.gov/pubmed/21544550note that students typically listen while doing something else – like driving. And while rewinding is possible, the inability to ask questions on the spot, or give feedback, or even ask a classmate for clarification, limit the utility of podcasting compared to traditional lectures.

The data about what we retain from tablets and online reading, compared to paper, is also concerning. It seems that screens and e-readers lack many of the subtle tactile features of paper that facilitate memorization and quick lookup – plus, many of us approach computers and tablets with a state of mind less conducive to learning. When surveyed, students seem to prefer paper for intensive studying (ref: http://www.emeraldinsight.com/journals.htm?articleid=1941334 ) and score higher in comprehension, when compared to those reading a PDF (ref: http://journals.ohiolink.edu/ejc/article.cgi?issn=08830355&issue=v58inone_c&article=61_rltopvcseorc ).

All of this evidence may change, however, as a new generation of learners raised with tablets and online education matures. The technology certainly isn’t going away, and students have already largely voted with their feet in that they’ve shunned lectures.

So the task for medical schools and providers of CME is how to best manage this transition, maximizing engagement and retention, blending aspects of traditional learning for those who excelled in those formats, with new, less-tested models that make use of the technology students seem to prefer. And curriculum reform is a good opportunity for even the best traditional speakers to re-examine their lectures, freshen up their material, and make a more engaging presentation.

None of us will ever forget diagnosing that first aortic dissection or first champagne spinal tap, and medical educators like Prober plan to use such memorable patient cases as a framework for their basic medical education.  For most of us, mastering the colossal amount of information presented in medical school required repetition of material in as many forms as possible.  By giving students a patient-centered, engaging format for essential concepts, retention can improve, and enhance application of those concepts in a clinical setting.

Medical students tend to be adaptable and capable, and will certainly navigate the curricular reform they’ve helped instigate, one way or another. But perhaps the greatest risk in flipping the classroom is abandoning traditional mentorship and classmate camaraderie.

If it’s done right, the new model of teaching may provide the space or time for more meaningful interactions between students and their professors, and amongst themselves as they demonstrate what they’ve learned. But it’s easy to imagine students isolated by technology, more involved in their tablets and laptops than the people in front of them. The opportunities to meet and learn from a wide variety of mentors and colleagues may be lost, in favor of online discussion forums and chat rooms.

As for us practicing clinicians, we face similar questions – should we skip the next CME trip or throw out our Xeroxed copies of the LLSA articles, in favor of PDFs and podcasts? Isolating ourselves even further sacrifices discussion, debate, and exposure to the expertise of outstanding leaders in our field.  Although today’s CME and journals are available in an online format, their greatest purpose is to enrich interaction with each other. 

No matter what we can learn on our own, practical experience and that of our peers offers an irreplaceable education. We are all eternal students and teachers, with or without the cramped lecture halls. As Sir William Osler wisely stated long before tablets and podcasts, “He who studies medicine without books sails an uncharted sea, but he who studies medicine without patients does not go to sea at all.”

 

 

The New Class

A cornerstone of the ‘flipped’ classroom model is that technology will guide students through the material – before coming to class, during interactive class activities, and afterwards (for exam prep). Here are some of the tools, and companies, trying to make a difference in this realm.

by Nicholas Genes, MD, PhD

Top Hat Monocle

blog.tophat.com

Already in use in 150 universities, Top Hat lets professors create polls – in seconds – that can gauge how their students are absorbing the material during the lecture. Students respond by tapping the answer on their smartphone, or texting a response. Professors can also deploy more sophisticated questions during lectures, prepared in advance, that require students to engage with various types of multimedia or text problems. After the lecture, students and professors can communicate in discussion forums, and there are tools for authoring and distributing additional course content. 

Medicine mooc list

mooc-list.com/tags/medicine

Massive Open Online Courses have proliferated – Coursera and EdX are the biggest and most full-featured services, but many others exist as well. Finding interesting courses used to mean browsing multiple sites – until the MOOC List directory appeared. You can browse by tags like Medicine or set up notifications so you’ll hear if a course that meets your specifications is announced. A few EM-related courses have already started to appear…

itunes U

apple.com/education/ipad/itunes-u

What started as a collection of free videos and podcasts from various universities has developed into an Apple-based vision of education. Through the iPad app, students can subscribe to a course from a major university, which would then appear as a button on an iTunes U shelf. Press that button, and you get the whole course syllabus – all the lectures, videos and handouts, in one place, available wherever your students want to learn. Students can add notes as they go or import additional documents, from their own reading or from the course director’s recommendations. UNC and Yale’s Schools of Medicine, among others, have put courses online, and most of it is free. 

Studyblue

studyblue.com

StudyBlue is a free web and app-based system that lets you create flashcards for a class – or browse other users’ flashcards for the same or similar courses. It’s free to use, but editing the cards (changing font, bolding or underlining text) requires a monthly fee. There’s real promise in the idea of being able to quiz yourself on your phone during downtime, and the app makes it possible to export your notes into Excel or other formats. 

chegg

chegg.com

While Chegg is a wildly successful online textbook rental service (they recently had an IPO valuing the company at $1 billion), they’re expanding to include round-the-clock answers to students’ questions. Answers come from paid experts or other students, or directly from textbooks (Chegg asks what books your course requires). Students are rewarded for rating the quality of the answers.

 

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