Effectiveness of the flipped classroom versus the traditional teaching method in enhancing learning among undergraduate medical students

Background: The flipped classroom is a form of interactive teaching strategy in which traditional learning is reversed by delivering core content outside the classroom and moving activities into the classroom. This study aimed to determine the effectiveness and medical students’ perception of flipped classroom. 

Methods: This quasi-experimental study included 100 first-year medical students who were divided into four groups (A, B, C, D), with 25 students in each group.  Groups A and C received didactic lectures, while groups B and D participated in flipped classroom. Thereafter, there was a crossover for ethical purposes. All students took multiple-choice pre-tests and post-tests, and there was also a retention test two weeks after the flipped classroom sessions. Students were further divided based on their pre-test scores into two categories: the <50% and the =50% category. Wilcoxon and Mann-Whitney tests were used to analyse the data for statistical significance. Student perceptions were collected by Google questionnaire.

Results: The result showed a significant improvement in the post-test marks for both the teaching learning methods. However, the flipped classroom groups outperformed the didactic groups, with mean post-test scores of 82.2 (10.8) and 84.2 (10.3) for the <50% and =50% groups, respectively, compared to 63.2 (9.4) and 72.4 (14.9) for the traditional groups, with a P <0.001. Knowledge retention was also notably better in the flipped classroom groups. The students' feedback supported flipped classroom method.

Conclusion: The flipped classroom boosts students’ performance and encourages active participation and higher order thinking in them. It can be adopted to make the MBBS students self-directed and lifelong learners.

The competency-based medical education for undergraduate medical students emphasises on interactive teaching learning methods like the flipped classroom. In our study, the flipped classroom strategy improved learning outcomes in undergraduate medical students, especially among those with poor baseline academic performance. This interactive, student-centred method excelled at stimulating knowledge retention, active participation, and engagement over traditional lectures.

The introduction of the competency-based medical education (CBME) curriculum by the National Medical Council of India (NMC) has marked a paradigm shift to more interactive classes from the traditional didactic lecture class.  The students participate actively in interactive classes, and higher-order thinking is encouraged [1]. Now, medical colleges all over our country are trying to bring modifications to the ongoing educational programs and various teaching-learning methods to inculcate the essence of self-directed learning to make them become lifelong learners. It will also help them to develop confidence to take “responsibility for their learning” [2]. One of the recent techniques adopted for interactive classes is the flipped classroom model (FCR) of teaching. The FCR potentially support student learning, so it is gaining momentum in medical education [3].

 

The FCR method is significantly adopted in the healthcare educational system to motivate and facilitate student participation in teaching and learning. In this method, students read the learning materials outside the class, giving more time for interactive activities in the class. This current medical education system aims to enable students to turn theory into practice [4]. In the previous traditional method of didactic lectures, the subject expert delivers the lecture to a large group of students. It consumed a lot of time, and the role of students in a lecture class was usually passive in the form of listening, understanding the concepts or taking notes, and having little opportunity to interact during the lecture hour [5]. The traditional didactic lectures helped to impart information to large groups of students. Still, they failed to develop the knowledge and problem-solving skills required in clinical practice in the students. “Flipped learning or the ‘flipped classroom’ is a strategy that reverses traditional learning by delivering core content outside of the classroom (often online), and moves activities more traditionally thought of as ‘homework’ into the classroom” [6].

 

The FCR is a type of “blended learning” where the students learn the “core” content of a topic before the lecture class either from the available resources, such as online resources or already circulated handout materials, books, class notes, etc. The main advantage of the FCR is that the students can learn in their environment and at their own pace, and it can be customised as per the difficulty level of the topic. It results in better and more effective time management of a class. This new teaching-learning method, the FCR method, was introduced to utilise the time available for teaching-learning fruitfully and help in the active participation of medical students to meet their learning needs [7]. Because the flipped classroom is a new education model in Indian medical education, so strong comparative studies are still required to determine its effectiveness compared with conventional teaching methods. With the CBME model, in particular, little data are available quantifying how this pedagogic change affects students' learning outcomes, satisfaction, and the acquisition of skills. In addition, an understanding of students' attitudes to this pedagogy is also necessary in order to quantify its acceptability and identify potential limitations to its broader implementation. So, this study aimed to determine the effectiveness of the FCR method compared to the traditional classroom method and to study students' perceptions of the newly introduced teaching-learning method.

This Study participants
This quasi-experimental study was conducted in the Department of Physiology, IMS and SUM Hospital, Bhubaneswar, India between January and June 2022. First-year medical students of the 2021-22 batch participated in the study. Students who were absent during the study period were excluded from the study. The study was undertaken after receiving the Institutional Ethical Committee clearance and obtaining informed consent from all the participants. 

 

The calculated sample size from a batch of 150 medical students was about 109 at a 95% confidence level and 5% margin of error using the finite population correction formula (n=N/1+N.e2 where N=150 and e=0.05.  Even though the calculated sample size was 109, 100 students (66.7% of the population) were included in the study based on logistical considerations. This was felt to be sufficient to ensure statistical power for quantitative analysis.

 

Data was gathered through a mix of objective assessments and structured feedback. For each teaching session-Didactic and Flipped Classroom (FCR)-students took a multiple-choice question (MCQ) test of 10 marks. These test items were crafted to evaluate both their knowledge and problem-solving skills. Separate question papers were created for the pre-test and post-test, ensuring they were of similar difficulty. The MCQs were based on standard Physiology textbooks, and to ensure content validity, four subject experts and four faculty members from the Medical Education Unit (MEU) reviewed them. All students participated in both the pre-test and post-test evaluations that matched their instructional method. Moreover, a retention test (also 10 marks) using MCQs was conducted two weeks after the FCR sessions to evaluate the knowledge retention across both teaching methods. To gauge perceptions, student feedback on the FCR method was collected through a pre-validated structured questionnaire. This questionnaire included questions covering various aspects of the flipped classroom experience, as well as students’ preferences for teaching and learning methods. The feedback form was developed based on a literature review, and its validity was confirmed by the same panel of subject experts and MEU members. The questionnaire was distributed digitally via google form.

 

 

Statistical analysis 
Statistical analysis was done using the SPSS software, version 18.0. Results were expressed in frequencies and percentages. The Wilcoxon signed-rank test was used to find the statistical significance between the pre-test and post-test marks in both categories. The post-test marks of both the T-L methods were compared by the Mann-Whitney U test between the categories. A p-value less than 0.05 was considered to be statistically significant.

This generation's medical students are losing interest in the didactic form of lectures [8], which is evident from their poor attendance and poor performance [9-12]. Students are lacking proper training in problem-solving and critical-thinking skills [13]. They are also not very much aware of self-directed learning. However, the students show interest in interactive learning [14]. The FCR fosters a student-centric approach, which helps students to develop lifelong learning skills [15]. Interactive learning like FCR gives a chance for individualised education. The students read the study materials conveniently and use face time more efficiently. The increasing role of FCR in enhancing the students' involvement and encouraging them to take responsibility for their learning has been broadly accepted by medical teachers [3]. As per Bloom’s Revised Taxonomy, the classroom is for lecture classes, which helps in the acquisition of knowledge and comprehension of facts, whereas FCR helps in long-term learning of the topics as it focuses on the identification of the learning needs of the students and involves ‘application, analysis, and evaluation’ of the knowledge. It consists of the principle of ‘learning by doing’ [16, 17].

 

 

 

The analysis of 82 papers by systemic review indicated that flipped class learning was a more favourable approach to motivating and engaging the students. However, there is little evidence about its effectiveness in retaining knowledge. In our study, we found FCR to be an interactive pedagogical tool that needs to be introduced early in medical education as it (i) helps the students to learn the subject assigned at their own pace, (ii) meaningfully use technology in learning the subject, (iii) helps in motivating students for self-directed learning, and (iv) enrich students with in-depth knowledge on the topic and facilitates conceptual learning. Memory retention was better for students of the flip class group than those who attended a didactic lecture in both groups. A meta-analysis of 46 papers with more than 9,000 participants revealed higher academic performance with flipped learning compared to a lecture-based approach [22]. Applying innovative methods like FCR in the teaching method can be rewarding. This type of student-centred approach enhances the lifelong learning ability of students. FCR promotes active learning by doing things and thinking about what they are doing. Based on Kolb’s four learning styles, it was found that flipped sessions were more effective than the traditional method. In our study, students found FCR beneficial because it was student-friendly [23]. They reported that they could understand the basic concepts and that it was more active and provided an opportunity for one-on-one interaction within the group. Previous researchers have reported receiving a positive response to the FCR method from students and teachers’ feedback. Zhao and Ho's analysis of students' feedback favoured FCR, although they did not find any improvement in students' academic performance following FCR in their studies. Studies have also concluded that students found FCR more beneficial because it engages them and facilitates interaction between students [24]. In our study, students showed that FCR improved their learning of the topic and their confidence to answer in the final exam. They also recommended teaching more topics using this method. In the studies of Veeramani et al. and Memon et al., students’ response to the FCR was hugely positive because the FCR approach met the learning objectives compared to didactic teaching [25, 26]. Buchner, in his article, pointed out that students were satisfied with this method as they got immediate feedback on their performance [27]. Szparagowski, in his project on flipped classrooms, mentioned some notes by students [28]. In this, students mentioned the benefits of FCR: it is less time-consuming than normal homework, and they can study from the videos at their convenience. 

They mentioned that FCR is a beneficial method because they can access multiple links and get help, and it introduces the topic before learning in class. In our study, students liked FCR because of their interactive nature and application-based discussion. They also found reading from recorded lectures and videos more convenient at home. Our findings are similar to a study by Nouri, who stated low achievers significantly reported more positively than high achievers and their perceived increased learning [29]. The significant challenges in implementing FCR are that, as almost all of us are acquainted with didactic lectures, a lot of preparation is needed both on the part of the students and teachers for its implementation. Increased workload and time constraints are other challenges. Students (i) have to be aware of self-directed learning; (ii) have to be ready for the class from the pre-reading material; (iii) have to know how to use smartphones and to access the internet; and (iv) need to be prepared with the assignments. Teachers (i) have to sort and list important pre-reading material, (ii) come prepared with lecture materials to the class in the form of MCQs, and (iii) provide the assignment materials like flowcharts, diagrams, etc. The strength of our study is that it employs a crossover design whereby each participant is exposed to both the conventional lectures and the flipped classroom approach. This not only amplifies the learning process but also ensures ethical integrity in providing equity of exposure to the learning strategies. We have divided the students into two groups, the <50% group and the =50% group, which helped us to identify the low achievers and to find out whether the new T-L method was useful for them or not. The major limitation of our study was the time constraint, under which we could do FCR only on a few topics with students of one batch and faculty members of the first phase only. A multicentric study involving multiple medical colleges and including a larger number of students and faculty members will help find out the actual effectiveness of the FCR.

 

Conclusion
Our study revealed that there is a marked improvement with FCR. The knowledge-retaining capacity was also better with students taught by the FCR method. It stands out as a promising strategy for cultivating self-directed, lifelong learners in the field of medical education. We recommend that FCR should be implemented in undergraduate medical teaching as it is an established teaching-learning tool that helps students gain a better understanding of the subjects compared to traditional Didactic lectures. 

We are grateful to the Dean, Institute of Medial Sciences  and SUM Hospital Bhubaneswar for the extended research facility at the Medical Research Laboratory. The authors also acknowledge Dr. Debasmita Dubey, MRL Lab, Institute of Medial Sciences and SUM Hospital Siksha ‘O’ Anusandhan University for providing necessary facilities and support.

Conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: DM, AM, TM, AM, PKS. Drafting the work or reviewing it critically for important intellectual content: DM, AM, TM, AM, PKS. Final approval of the version to be published: DM, AM, TM, AM, PKS. Accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: DM, AM, TM, AM, PKS.