How we are flipping EM education

Lately, lecture, that venerable tool in the educator’s toolkit, has come under considerable fire for being inefficient and ineffective². This is not entirely the fault of lecture. The lecture is simply a tool and its effectiveness is dependent upon the user. Unfortunately, too few teachers engage in deliberate practice to improve their lectures (or design their presentations). Additionally, medical education has become too reliant on the lecture as the “best” tool to deliver our message. Perhaps this is why, in recent years, we have seen a rapid expansion in alternative teaching strategies, from problem-based learning to simulation. The Flipped Classroom is one such strategy that captures the advantages of lecture AND active learning strategies.

What is the Flipped Classroom?

At its most basic, Flipped Teaching is a form of instruction where students are given the content, usually in the form of a video, to independently view by themselves. Class time, previously used by the teacher to deliver the lecture, is now used for application of the knowledge, problem solving, and practical experience.

While Salman Khan, creator of the Khan Academy, popularized the concept in his 2011 TED Talk, the credit for initially applying the concept belongs to Eric Mazur. A physics teacher at Harvard, he noticed that despite consistently high evaluations for his teaching, his students couldn’t apply basic concepts in physics. He inadvertantly discovered that peer to peer discussion was critical in clarifying student misperceptions and went on to create an early flipped classroom in which students watched videos and then interacted with each other in order to solve complex problems.

Fast-forward to Valentine’s Day, 2005. YouTube is born. Suddenly, technology that was previously only available to educators with resources becomes universally available. As a platform, YouTube made it easy for educators to share videos with their learners. Educational innovators quickly seized upon this opportunity to provide instruction to their learners. Jonathan Bergmann and Aaron Sams, authors of Flip Your Classroom, took advantage of this early technology as an attempt to support learners who are frequently absent from their rural classroom³. After some experimentation, they came to realize that Flipped Learning offered many advantages:

• Efficiency
• Reproducible, scalable, and customizable content
• Student centered content
• Increased student to teacher interaction
• Increase student and student interaction
• Students assume the responsibility for learning

After several years, they have expanded their curriculum into what is now is termed ‘Flipped Mastery’. In the mastery model, students are allowed to progress through the curriculum in an asynchronous fashion, learning the objectives of the curriculum at their own pace.

With this model, the teacher’s role changes. Instead of being the “Sage on the Stage,” the teacher becomes a “Guide on the Side.” The teacher’s role within the flipped model is to provide:

• Accountability
• Expert feedback
• Concept Clarification
• Project/activity oversight

Notice that lecture does still have a role within this model. Instead of using class time to deliver the content using a passive delivery vehicle, they utilize class time for active learning. Students view the lectures as videos. These videos offer several advantages. Students can pause and rewind their teacher. In addition, lectures delivered through video are easily reusable from class to class. The best videos also take cognitive load into account and are appropriately brief.

How to Implement Flipped Education

Similar to the experience of Bergmann and Sam’s, our residency “accidentally” stumbled into flipped education, albeit a low-tech version. When our program started in 2008, we were faced with providing high-quality education by very few faculty members. If we were to use other models and provide a majority of the content via a weekly lecture series, each faculty member would have to deliver a lecture a week. Given the inordinate amount of time this would require, we sought another solution. Instead, we turned to the medical literature. We looked for “classic” papers in emergency medicine and succinct review articles. Residents were assigned several papers to read every week and then met in small groups to discuss and debate the topics. A comparison is provided below:

“Traditional Residency”

• Lecture: 50 minutes
• Break: 10 minutes
• Lecture: 50 minutes
• Break: 10 minutes
• Lecture: 50 minutes
• Break: 10 minutes
• etc

“Our Model”

• Updates: 20 minutes
• Test: 10 minutes
• Small group discussions: 80 minutes
• Break: 10 minutes
• Simulation/Oral boards: 50 minutes
• Break: 10 minutes
• Guest lecture/Morbidity and Mortality Conference/Clinical Case Presentation: 50 minutes

Initially, we hit many roadblocks. Our chosen literature was not received positively by the learners. The weekly modules did not have a logical flow (asthma one week, DKA the next, back to Pulmonary thromboembolic disease). We also faced technology problems. We were utilizing a platform to host the PDF files that didn’t allow for customization. Instead, hundreds of documents were in a single file folder. We took the learner feedback and have been continually making improvements. We created a wiki and used it to host the entire curriculum. This also allowed us to incorporate images, podcasts, and videos into the curriculum. We also continuously assess the included literature for its relevance. Each week learners give us feedback on articles that they found helpful and eliminate those that do not add to our clinical practice. Currently, the Model of the Clinical Practice of Emergency Medicine is taught in 82 separate modules, delivered twice throughout a residents education.

As an educator, the most enjoyable part of flipped education is observing the learners taking responsibility for their own learning. The learners are able to ask critical questions of their practice after reading the literature. The discussion also allows them to explore the experiences of their faculty in great depth, thus gaining tacit knowledge. When we meet as a small group, the instructor is given free reign to determine how to utilize that time. This variety keeps the small groups interesting and the learners engaged.

Activities that we have utilized during our group time include:

• Peer led discussions
• Case-based instruction
• Pro-Con debates
• Projects, such as developing a departmental postpartum hemorrhage protocol
• Shared Mind Map creation
• Hands-on demonstrations (slit lamp, ENT toolbox, neuro exam)

Our curriculum is constantly evolving. New this year is the Clinical Case Presentation. This hour-long “cognitive apprenticeship” allows learners to present interesting or difficult cases to a panel of faculty members. As the case is revealed, we must think out loud, elaborating our reasoning for asking specific questions or ordering specific tests, until the diagnosis is revealed. We have also begun team-based quality improvement projects in an attempt to teach 21st-century skills to our learners.

The Future

The next logical progression of our curriculum is to incorporate components of mastery learning. Within this model, students are allowed to progress through a curriculum at their own pace. Mastery learning is directly applicable to Competency-Based Medical Education, and offers the promise that we may finally have an alternative to the “tea-steeping” model of medical education⁴.

References

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