The Flipped Classroom: Abandon the Sage on the Stage, and Embrace the Guide on the Side

Traditional in-class lectures continue to be the main modality for delivery of core curricula throughout medical education¹. This teaching model persists despite evidence that students’ attention declines significantly and steadily after the first 10 minutes of class, and that students are able to recall only about 20 percent of material presented during a typical one-hour lecture.^1–5 Particularly in the arena of medical education, research has shown that students who are actively engaged in constructing their own learning have increased learning gains and improved motivation and attitudes compared with those who passively listen to traditional lectures.^6,7 Active learning techniques—such as teamwork, debates, and case studies—prompt student engagement and encourage them to explore attitudes and values while fostering student-centered learning and motivation to acquire new knowledge.⁸ Active learning also stimulates higher-order thinking, problem solving, and critical analysis⁹—skills crucial for aspiring health professionals.

Combining what is known about active adult learning with advancements in instructional technology has led to the development of the flipped classroom model in which the traditional lecture is a student's homework and in-class time is spent on collaborative, inquiry-based active learning.¹⁰ Student-centered instructional models, including the flipped classroom, are grounded in the constructivist theory of learning, in which learners construct knowledge for themselves, as in each learner actively constructs meaning (learns) as new information is linked to prior knowledge and experience.^11,12 The core principle of constructivism applied to learning is that the environment is learner-centered and learning is an active rather than passive endeavor. The constructivist approach emphasizes self-direction, active inquiry, independence, and individuality and the instructor’s role is to foster critical reflection and facilitate the application and deeper understanding of new concepts.¹³ Over the years, educators have sought methods for applying the constructivist theory to the classroom.¹¹ The flipped classroom learning environment capitalizes on the increased opportunities for constructivist learning that technology has provided.¹⁴

Flipping the classroom has recently gained prominence due to advances in technology and easy access to computers and other mobile devices.¹⁵ Instructors are thereby able to provide a variety of didactic material outside of class that is both accessible and conducive to student-centered learning. Utilizing the materials, students are responsible for their own knowledge acquisition and are expected to come to class with a basic understanding of the subject so that they can fully participate and engage in the in-class discussion or activity. Initial learning therefore is self-paced and self-guided, enabling students to control when and how much content they view. Interactivity then occurs in the classroom when the students work collaboratively to solve problems and evaluate and synthesize ideas and concepts. Learning deepens as the learner develops new ideas and alters existing ideas when interacting with content and collaborating with other learners and the instructor.^8,11,16 This approach allows educators to optimize their time, and increases educator-student interaction as the educator is present when students attempt to analyze and apply their new knowledge.^17,18

There is a growing body of literature supporting successful implementation of a flipped classroom within health care professions.^18–25 Multiple studies demonstrate that learners not only enjoy the flipped classroom, but that it is often times preferred over other instructional approaches.^{18–20,22,23} In a study by McLaughlin et al., a flipped classroom was implemented for a first-year pharmaceutics course.¹⁸ Assessment of learner attitudes and preferences using a voluntary pre- and post-course survey demonstrated a significant increase in the intervention group’s perception of instructors encouraging active learning and being required to come to class prepared. O’Connor and colleagues, reporting on their experience implementing a flipped classroom for their radiology clerkship, found that students in the flipped classroom group experienced higher task value (p<0.001), less boredom (p<0.001), and had greater enjoyment (p<0.001) than traditional classroom controls. In a study by Liebert et al., a flipped classroom was implemented for students enrolled in the surgery clerkship.¹⁹ Compared to historic controls taught with traditional lectures, achievement on the NBME Shelf Examination was not significantly different. However, the authors found that students exposed to the flipped classroom showed significantly increased interest in surgery as a career compared to the historic controls, with 90 percent reporting that the flipped classroom curriculum contributed to their increased interest in surgery.

The flipped classroom is also an effective instructional technique in regards to actual learning.^{18,20,22,24,26,27} O’Connor et al. implemented a flipped classroom for students on their radiology clerkship, alternating each block between flipped learning and traditional didactic lectures.²⁴ The authors found a 5.36 percent greater score increase in pretest versus posttest performance for those enrolled in the flipped classroom (p = 0.013). In a study by Martinelli et al., second-year anesthesia residents were randomly assigned to either a flipped classroom or traditional lecture model for an American Board of Anesthesiology Basic Examination review course.²⁵ There was no significant difference between groups in posttest performance or in improvement between pretest and posttest scores. However, follow-up testing at four months revealed greater knowledge retention in the flipped classroom group (adjusted mean = 6 percent; p = 0.014). Tune and colleagues evaluated a flipped classroom curriculum for their cardiovascular, respiratory and renal physiology courses.²⁷ The results of the study demonstrated that within a comparable group of graduate students, participants in the flipped course scored significantly higher (p < 0.05) on the cardiovascular, respiratory, and weighted cumulative sections by an average of >12 percentage points.

There are a number of factors that can contribute to successful implementation of a flipped classroom. The flipped method represents a significant shift away from traditional PowerPoint-based lectures, and faculty generally require additional time and expertise in order to create the online materials and hold interactive in-class sessions.²⁸ One of the main concerns expressed by educators about converting to a flipped classroom is the amount of time and work involved, though most of this time is up-front, and once the online resources have been created, there is little to no additional time requirement.¹⁷ Of note, instructors may also minimalize additional time requirements by utilizing electronic learning libraries already in place such as the American College of Surgeons (ACS) Fundamentals of Surgery, ACS Medical Student Core Curriculum, OnlineMedEd, GIBLIB, and numerous others that can be found on dedicated YouTube channels and free websites. Similar to faculty, time management is the most common concern among students. Given the busy nature of most clerkships and rotations along with the host of competing concerns of students, it is important not to squander the learners’ energy and time.

1. Prober CG, Heath C. Lecture halls without lectures—a proposal for medical education. N Engl J Med. 2012;366(18):1657-1659.
2. Hartley J, Cameron A. Some observations on the efficiency of lecturing. Educational Review. 1967;20(1):30-37.
3. MacManaway LA. Teaching methods in higher education–innovation and research. Higher Education Quarterly. 1970;24(3):321-329.
4. Prober CG, Khan S. Medical education reimagined: a call to action. Academic medicine : journal of the Association of American Medical Colleges. 2013;88(10):1407-1410.
5. Stuart J, Rutherford R. Medical student concentration during lectures. The lancet. 1978;312(8088):514-516.
6. Hrynchak P, Batty H. The educational theory basis of team-based learning. Medical teacher. 2012;34(10):796-801.
7. Freeman S, O'Connor E, Parks JW, et al. Prescribed active learning increases performance in introductory biology. CBE-Life Sciences Education. 2007;6(2):132-139.
8. Prince M. Does active learning work? A review of the research. Journal of engineering education. 2004;93(3):223-231.
9. McKeachie WJ. Teaching and learning in the college classroom: A review of the research literature. Vol 86: University of Michigan Press; 1986.
10. Bergmann J, Sams A. Flip your classroom: Reach every student in every class every day. International Society for Technology in Education; 2012.
11. Sternberg R. Applying psychological theories to educational practice. American Educational Research Journal. 2008;45(1):150-165.
12. Roustaee R, Abd. Kadir S, Asimiran S. A review of Constructivist Teaching Practices. Middle-East J. Sci. 2014;19:145-152.
13. Gordon M. Between constructivism and connectedness. Journal of Teacher Education. 2008;59(4):322-331.
14. Koohang A, Riley L, Smith T, Schreurs J. E-learning and constructivism: From theory to application. Interdisciplinary Journal of E-Learning and Learning Objects. 2009;5(1):91-109.
15. Davies RS, Dean DL, Ball N. Flipping the classroom and instructional technology integration in a college-level information systems spreadsheet course. Educational Technology Research and Development. 2013;61(4):563-580.
16. Baeten M, Struyven K, Dochy F. Student-centered teaching methods: Can they optimise students’ approaches to learning in professional higher education? Studies in Educational Evaluation. 2013;39(1):14-22.
17. Moffett J. Twelve tips for "flipping" the classroom. Med Teach. 2015;37(4):331-336.
18. McLaughlin JE, Roth MT, Glatt DM, et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(2):236-243.
19. Liebert CA, Lin DT, Mazer LM, Bereknyei S, Lau JN. Effectiveness of the Surgery Core Clerkship Flipped Classroom: a prospective cohort trial. The American Journal of Surgery. 2016;211(2):451-457.e451.
20. Belfi LM, Bartolotta RJ, Giambrone AE, Davi C, Min RJ. "Flipping" the Introductory Clerkship in Radiology: Impact on Medical Student Performance and Perceptions. Academic radiology. 2015.
21. Bishop JL, Verleger MA. The flipped classroom: A survey of the research. Paper presented at: ASEE National Conference Proceedings, Atlanta, GA2013.
22. Wong TH, Ip EJ, Lopes I, Rajagopalan V. Pharmacy students' performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. American journal of pharmaceutical education. 2014;78(10):185.
23. Young TP, Bailey CJ, Guptill M, Thorp AW, Thomas TL. The flipped classroom: a modality for mixed asynchronous and synchronous learning in a residency program. The western journal of emergency medicine. 2014;15(7):938-944.
24. O'Connor EE, Fried J, McNulty N, et al. Flipping Radiology Education Right Side Up. Academic radiology. 2016;23(7):810-822.
25. Martinelli SM, Chen F, DiLorenzo AN, et al. Results of a Flipped Classroom Teaching Approach in Anesthesiology Residents. J Grad Med Educ. 2017;9(4):485-490.
26. Moravec M, Williams A, Aguilar-Roca N, O'Dowd DK. Learn before lecture: a strategy that improves learning outcomes in a large introductory biology class. CBE-Life Sciences Education. 2010;9(4):473-481.
27. Tune JD, Sturek M, Basile DP. Flipped classroom model improves graduate student performance in cardiovascular, respiratory, and renal physiology. Advances in physiology education. 2013;37(4):316-320.
28. Kurup V, Hersey D. The changing landscape of anesthesia education: is Flipped Classroom the answer? Current Opinion in Anesthesiology. 2013;26(6):726-731.
29. Taylor DCM, Hamdy H. Adult learning theories: Implications for learning and teaching in medical education: AMEE Guide No. 83. Medical Teacher. 2013;35(11):e1561-e1572.
30. Lage MJ, Platt GJ, Treglia M. Inverting the classroom: A gateway to creating an inclusive learning environment. The Journal of Economic Education. 2000;31(1):30-43.

Catherine E. Lewis, MD, MEd, is an assistant professor of surgery, Trauma, General Surgery & Surgical Critical Care, David Geffen School of Medicine at UCLA.