Replacing Lectures with Small Groups: The Impact of Flipping the Residency Conference Day

Foundations of Emergency Medicine: Impact of a Standardized, Open-access, Core Content Curriculum on In-Training Exam Scores

Introduction

Learners frequently benefit from modalities such as small-group, case-based teaching and interactive didactic experiences rather than passive learning methods. These contemporary techniques are features of Foundations of Emergency Medicine (FoEM) curricula, and particularly the Foundations I (F1) course, which targets first-year resident (PGY-1) learners. The American Board of Emergency Medicine administers the in-training exam (ITE) that provides an annual assessment of EM-specific medical knowledge. We sought to assess the effect of F1 implementation on ITE scores.

Methods

We retrospectively analyzed data from interns at four EM residency programs accredited by the Accreditation Council for Graduate Medical Education. We collected data in 2021. Participating sites were geographically diverse and included three- and four-year training formats. We collected data from interns two years before (control group) and two years after (intervention group) implementation of F1 at each site. Year of F1 implementation ranged from 2015-2018 at participating sites. We abstracted data using a standard form including program, ITE raw score, year of ITE administration, US Medical Licensing Exam Step 1 score, Step 2 Clinical Knowledge (CK) score, and gender. We performed univariable and multivariable linear regression to explore differences between intervention and control groups.

Results

We collected data for 180 PGY-1s. Step 1 and Step 2 CK scores were significant predictors of ITE in univariable analyses (both with P < 0.001). After accounting for Step 1 and Step 2 CK scores, we did not find F1 implementation to be a significant predictor of ITE score, P = 0.83.

Conclusion

Implementation of F1 curricula did not show significant changes in performance on the ITE after controlling for important variables.

The effects of flipped classrooms to improve learning outcomes in undergraduate health professional education: A systematic review

Background

The 'flipped classroom' approach is an innovative approach in educational delivery systems. In a typical flipped class model, work that is typically done as homework in the didactic model is interactively undertaken in the class with the guidance of the teacher, whereas listening to a lecture or watching course-related videos is undertaken at home. The essence of a flipped classroom is that the activities carried out during traditional class time and self-study time are reversed or 'flipped'.

Objectives

The primary objectives of this review were to assess the effectiveness of the flipped classroom intervention for undergraduate health professional students on their academic performance, and their course satisfaction.

Search Methods

We identified relevant studies by searching MEDLINE (Ovid), APA PsycINFO, Education Resources Information Center (ERIC) as well as several more electronic databases, registries, search engines, websites, and online directories. The last search update was performed in April 2022.

Selection Criteria

Included studies had to meet the following criteria: Participants: Undergraduate health professional students, regardless of the type of healthcare streams (e.g., medicine, pharmacy), duration of the learning activity, or the country of study. Intervention: We included any educational intervention that included the flipped classroom as a teaching and learning tool in undergraduate programs, regardless of the type of healthcare streams (e.g., medicine, pharmacy). We also included studies that aimed to improve student learning and/or student satisfaction if they included the flipped classroom for undergraduate students. We excluded studies on standard lectures and subsequent tutorial formats. We also excluded studies on flipped classroom methods, which did not belong to the health professional education(HPE) sector (e.g., engineering, economics). Outcomes: The included studies used primary outcomes such as academic performance as judged by final examination grades/scores or other formal assessment methods at the immediate post-test, as well as student satisfaction with the method of learning. Study design: We included randomised controlled trials (RCTs), quasi-experimental studies (QES), and two-group comparison designs. Although we had planned to include cluster-level RCTs, natural experiments, and regression discontinuity designs, these were not available. We did not include qualitative research.

Data Collection and Analysis

Two members of the review team independently screened the search results to assess articles for their eligibility for inclusion. The screening involved an initial screening of the title and abstracts, and subsequently, the full text of selected articles. Discrepancies between the two investigators were settled through discussion or consultation with a third author. Two members of the review team then extracted the descriptions and data from the included studies.

Main Results

We found 5873 potentially relevant records, of which we screened 118 of them in full text, and included 45 studies (11 RCTs, 19 QES, and 15 two-group observational studies) that met the inclusion criteria. Some studies assessed more than one outcome. We included 44 studies on academic performance and eight studies on students' satisfaction outcomes in the meta-analysis. The main reasons for excluding studies were that they had not implemented a flipped class approach or the participants were not undergraduate students in health professional education. A total of 8426 undergraduate students were included in 45 studies that were identified for this analysis. The majority of the studies were conducted by students from medical schools (53.3%, 24/45), nursing schools (17.8%, 8/45), pharmacy schools (15.6%, 7/45). medical, nursing, and dentistry schools (2.2%, 1/45), and other health professional education programs (11.1%, 5/45). Among these 45 studies identified, 16 (35.6%) were conducted in the United States, six studies in China, four studies in Taiwan, three in India, two studies each in Australia and Canada, followed by nine single studies from Brazil, German, Iran, Norway, South Korea, Spain, the United Kingdom, Saudi Arabia, and Turkey. Based on overall average effect sizes, there was better academic performance in the flipped class method of learning compared to traditional class learning (standardised mean difference [SMD] = 0.57, 95% confidence interval [CI] = 0.25 to 0.90, τ 2: 1.16; I 2: 98%; p < 0.00001, 44 studies, n = 7813). In a sensitivity analysis that excluded eleven studies with imputed data from the original analysis of 44 studies, academic performance in the flipped class method of learning was better than traditional class learning (SMD = 0.54, 95% CI = 0.24 to 0.85, τ 2: 0.76; I 2: 97%; p < 0.00001, 33 studies, n = 5924); all being low certainty of evidence. Overall, student satisfaction with flipped class learning was positive compared to traditional class learning (SMD = 0.48, 95% CI = 0.15 to 0.82, τ 2: 0.19, I 2:89%, p < 0.00001, 8 studies n = 1696); all being low certainty of evidence.

Authors' Conclusions

In this review, we aimed to find evidence of the flipped classroom intervention's effectiveness for undergraduate health professional students. We found only a few RCTs, and the risk of bias in the included non-randomised studies was high. Overall, implementing flipped classes may improve academic performance, and may support student satisfaction in undergraduate health professional programs. However, the certainty of evidence was low for both academic performance and students' satisfaction with the flipped method of learning compared to the traditional class learning. Future well-designed sufficiently powered RCTs with low risk of bias that report according to the CONSORT guidelines are needed.

Pain Medicine Education in Emergency Medicine Residency Programs

Background Pain is a common complaint in the emergency department (ED), yet there is a lack of robust pain curricula in emergency medicine (EM) residency programs. In this study, we investigated pain education in EM residencies and various factors related to educational development. Methodology This was a prospective study collecting online survey results sent to Program Directors, Associate Program Directors, and Assistant Program Directors of EM residencies in the United States. Descriptive analyses with nonparametric tests were performed to investigate relationships between these factors, including educational hours, level of educational collaboration with pain medicine specialists, and multimodal therapy utilization. Results The overall individual response rate was 39.8% (252 out of 634 potential respondents), representing 164 out of 220 identified EM residencies with 110 (50%) Program Directors responding. Traditional classroom lectures were the most common modality for the delivery of pain medicine content. EM textbooks were the most common resource utilized for curriculum development. An average of 5.7 hours per year was devoted to pain education. Up to 46.8% of respondents reported poor or absent educational collaboration with pain medicine specialists. Greater collaboration levels were associated with greater hours devoted to pain education (p = 0.01), perceived resident interest in acute and chronic pain management education (p < 0.001), and resident utilization of regional anesthesia (p = <0.01). Faculty and resident interest in acute and chronic pain management education were similar to each other and high on the Likert scale, with higher scores correlating to greater hours devoted to pain education (p = 0.02 and 0.01, respectively). Faculty expertise in pain medicine was rated the most important factor in improving pain education in their programs. Conclusions Pain education is a necessity for residents to adequately treat pain in the ED, but remains challenging and undervalued. Faculty expertise was identified as a factor limiting pain education among EM residents. Collaboration with pain medicine specialists and recruitment of EM faculty with expertise in pain medicine are ways to improve pain education of EM residents.

Combing pre-workshop, web-based learning and hands-on workshop as a flipped classroom clinical skill training model during the COVID-19 pandemic

Objective

Due to the COVID-19 pandemic, there is a dramatic drop in in-person residency training due to the implementation of isolation and triage measurements. Here, we propose a new flipped classroom clinical skill training model utilizing a combination of pre-workshop, web-based learning and hands-on workshop that shortens in-person contact time to maintain residency training during the pandemic. Effectiveness of this training model was evaluated with a pre-test and post-test skills competency assessment, two-way feedback, and a five-point Likert scale structured survey questionnaire.

Materials and methods

The workshop was conducted in a flipped classroom fashion by the obstetrics and gynecology (OBGYN) department of a single tertiary teaching medical center covering topics from five OBGYN subspecialities. Every topic consisted of a pre-workshop, web-based, mini lecture (PWML) followed by a hands-on workshop (HW). All first to fourth year OBGYN residents were invited to attend the workshop. All the trainees were required to complete the PWML prior to the day of HW. The workshop consisted of rotational station for each topic and was conducted within one afternoon. A 0-100-point scale pre-test and post-test skills competency evaluation were performed for each station and was assessed by the attending doctor or fellow doctor of each subspeciality. Two-way feedback was done after the post-test evaluation. A five-point Likert scale structured survey instrument consisting of participant’s perceptions of the workshop design, relevance to clinical practice, and quality of instructors and materials was created during the curriculum development process and sent to each participant one month after the workshop.

Results

A total of 19 residents including five first-year, six second-year, three third-year, and five fourth-year residents completed the entire pre-workshop lecture, workshop, pre-test, and post-test. For all residents, the average post-test score of 5 stations was 95 and was significantly higher than the pre-test score of 60 (p < 0.001). For both junior residents and senior residents, the average post-test scores of 5 stations were also significantly higher than pre-test scores (p < 0.001). Survey generated one month after the workshop showed a high overall satisfaction with the workshop instructors on their professional knowledge, communication skills, and interactions between the instructors and trainees. The average satisfaction scores for manipulation of vaginal breech delivery (VBD), semen analysis (SA), cervical conization (CC), obstetrics anal sphincter injury (OASIS), and laparoscopic suture techniques (LST) were 4.84, 4.96, 4.92, 4.88, and 4.92, respectively The average score for practical application of the training materials, class design and teaching method, overall satisfaction of the session, and time scheduling was 4.84, 4.96, 4.96, and 4.48, respectively. The entire HW was completed within 180 min and was carried out within half a day.

Conclusion

With the implementation of isolation and triage measures in the COVID-19 pandemic, there is a dramatic drop in in-person exposure to all aspects of the residency training, in particular, non-emergent surgeries. Utilization of PWML saved 1/3 of in-person time and the entire workshop was completed within 180 min that could be carried out within half a day. The decrease of person-to-person contact time during the COVID-19 pandemic is necessary while still providing curriculum-based residency training in spite of decreased hands-on experience.

Development, Implementation, and Evaluation of an Open Access, Level-Specific, Core Content Curriculum for Emergency Medicine Residents

BACKGROUND

Leaders in graduate medical education must provide robust clinical and didactic experiences to prepare residents for independent practice. Programs traditionally create didactic experiences individually, requiring tremendous resources with variable content exposure and quality.

OBJECTIVE

We sought to create and implement a free, open access, learner-centric, level-specific, emergency medicine (EM) residency curriculum.

METHODS

We developed Foundations of Emergency Medicine (FoEM) Foundations I and II courses using Kern's model of curriculum development. Fundamental topics were identified through content guidelines from the American Board of Emergency Medicine. We incorporated learner-centric strategies into 2 flipped classroom, case-based courses targeting postgraduate year (PGY) 1 and PGY-2 residents. The curriculum was made freely available online in 2016. Faculty and resident users were surveyed annually for feedback, which informed iterative refinement of the curriculum.

RESULTS

Between 2016 and 2020, registration for FoEM expanded from 2 sites with 36 learners to 154 sites and 4453 learners. In 2019, 98 of 102 (96%) site leaders and 1618 of 2996 (54%) learners completed the evaluative survey. One hundred percent of responding leaders and 93% of learners were "satisfied" or "very satisfied" with FoEM content. Faculty and residents valued FoEM's usability, large volume of content, quality, adaptability, organization, resident-faculty interaction, and resident-as-teacher opportunities. Challenges to implementation included resident attendance, conference structure, technology limitations, and faculty engagement.

CONCLUSIONS

We developed and implemented a learner-centric, level-specific, national EM curriculum that has been widely adopted in the United States.

Medical Education in Pathology: General Concepts and Strategies for Implementation

CONTEXT.—

Pathology education must evolve as medical knowledge expands and disruptive technologies emerge. The evolution in pathology teaching practices accelerated as traditional teaching modalities were suspended in March 2020 during the coronavirus disease 2019 (COVID-19) pandemic.

OBJECTIVES.—

To provide pathologists an overview of established teaching paradigms and practical examples of how these paradigms may be applied to pathology education, emphasizing differences in graduate and undergraduate medical education as well as the challenges and promises of remote learning, as revealed by the COVID-19 pandemic.

DATA SOURCES.—

Selected peer-reviewed publications representing the field of educational social science.

CONCLUSIONS.—

Evidence-based methods described in education and social sciences can be effectively deployed in pathology education and especially remote learning, as necessitated by the current COVID-19 pandemic. Understanding established principles, such as cognitive load, competency-based learning, peer-assisted learning, and flipped classrooms may prove useful in developing effective, learner-centric content for pathology education.

Development of a health equity journal club to address health care disparities and improve cultural competence among emergency medicine practitioners

Health care disparities have been magnified by the COVID-19 pandemic. Only recently has the medical community acknowledged implicit bias and systemic racism as a public health emergency. Graduate medical education has been slow to adopt curricula beyond lecture-based formats that specifically address social determinants of health (SDOH) and its impact on communities. Curricula addressing unconscious (implicit) biases and their influence on patient care has not been widely adopted. The emergency department (ED) has a unique role in addressing health care disparities. Approximately 69% of emergency medicine residency programs incorporate cultural competency training in their curricula. Most are primarily lecture-based without a longitudinal component, and gaps exist in content, quality, and expertise of the presenters. Lecture-based formats may not be best suited to manage the nuanced conversations necessary to dismantle biases and socialized beliefs that result in disparities for marginalized communities. Reporting little or no education in medical school related to SDOH, residents acknowledge that barriers to care exist, but have limited or no knowledge of what those barriers are or how mitigate them. To improve health equity, understanding and competence in caring for culturally and ethnically diverse populations, we developed a monthly, longitudinal, SDOH- and cultural competency-based "health equity journal club" (HEJC) for all levels of ED staff. Four educational domains were developed, and specific content within each domain was selected based on predetermined criteria. Content for each session was mapped to the ACGME program and core competency milestone requirements, ACGME Clinical Learning Environment (CLER) mandates, and The Joint Commission's institutional recommendations for culturally competent care. The HEJC series has been successful in reducing barriers to identifying biases in health care; translating literature to clinical care; generating initiatives and interdisciplinary research; and cultivating interest in community health, health advocacy, and public policy.

One Room Schoolhouse: A Novel Intervention for Inspired Academic Half-Day Learning in Distributed Campus Settings

INTRODUCTION

Some studies on academic half days (AHDs) suggest that learning in this context is associated with a lack of educational engagement. This challenge may be amplified in distributed campus settings, where geographical disadvantages demand reliance on videoconferencing or considerable time spent travelling to in-person learning events. Concerns about the educational effectiveness of AHDs by learners within our distributed campus setting led to the development and evaluation of the One Room Schoolhouse (ORS), a unique, evidence-informed, community-based curriculum that partially replaced the AHD sessions delivered at the main campus. It was hypothesized that creating an AHD experience that was clinically reflective of the community in which residents practiced and where residents were given the autonomy to implement novel pedagogical elements would result in better test scores and improved learner satisfaction among ORS learners.

METHODS

The ORS was implemented at McMaster University's Waterloo Regional Campus in 2017. Residents across training cohorts (N = 9) engaged in co-learning based on scenarios co-developed from clinical experiences within the region. The learning approach relied on multiple, evidence-informed pedagogical strategies. A multi-method approach was used to evaluate the ORS curriculum. Between-subject analyses of variance were used to compare scores on practice exams (COPE and PRITE), in-training assessment reports (ITARs), and objective structured clinical exams (OSCEs) between learners who took part in the ORS and learners at the main campus. A semi-structured focus group probing residents' experiences with the ORS was analyzed using interpretive description.

RESULTS

ORS learners significantly outperformed learners at the main campus on the November OSCE (p = .02), but not on the COPE, PRITE, ITARs, or September OSCE (p's < .05). Qualitative themes suggested advantages of the ORS in inspiring learning, engaging learners, and improving self-confidence in knowledge acquisition. These findings are aligned with the broader literature on learner agency, social development, and communities of practice.

CONCLUSION

While the quantitative data only showed a significant difference between the 2 curricula on 1 measure (ie, the November OSCE), the qualitative findings offered an opportunity for educators to reimagine what medical education might consist of beyond the confines of a "traditional" AHD. Creating opportunities to enhance personal agency when acquiring knowledge, inspiring engagement about patient-related problems, and incorporating interdisciplinary learning through community engagement were critical pedagogical elements that were attributed to the success of the ORS.

Strategic Considerations for Applying the Flipped Classroom to Neurology Education

Nowadays, the "flipped classroom" approach is taking the center stage within medical education. However, very few reports on the implementation of the flipped classroom in neurology have been published to date, and this educational model still represents a challenge for students and educators alike. In this article, neurology educators from the American Academy of Neurology's A. B. Baker Section on Neurological Education analyze reports of flipped classroom in other medical/surgical subspecialties, review the current implementation in neurology, and discuss future strategies to flip the neurology curriculum through contextualization of the benefits and the consequences. ANN NEUROL 2020;87:4-9.

Reshaping the residency environment to enhance education and mitigate burnout

Burnout remains a widespread issue in graduate medical education, with current trends to mitigate burnout shifting toward institutional systematic interventions as opposed to personal individual interventions. In this article, we propose utilizing Knowle's adult learning theory in conjunction with Maslach's organizational context for burnout to implement systemic changes within the postgraduate training environment that we posit would both optimize the learning experience and reduce the incidence of burnout.

Teaching "Shock Pathophysiology" by Flipped Classroom

Objective

To assess usefulness of flipped style of teaching conducted as small-group format in Cardiovascular and Respiration module for Year-I undergraduate medical students at Aga Khan University.

Methods

The study was planned and conducted over a period of eight months from March to October 2017 including the time taken for planning, mock run, execution followed by analysis and dissemination. It was carried out at the Aga Khan University Medical College, Karachi. Pre and post test scores of students after flipped class room sessions was compared. Moreover, perception of students was assessed on Likert scale (0-4) by a pretested validated questionnaire.

Results

The mean pre-test scores of the students was 4.86 ± 0.91 which improved to 6.09 ± 0.81 (p = 0.021) after attending the flipped class session. Students approved that the frame work helped to promote their learning motivation and engagement with improvement in understanding of the course materials and enhancement of learning during Face to Face activity.

Conclusions

The flipped classroom approach showed promise in teaching and learning of 'Pathophysiology of Shock' by clinical scenarios in small group discussions. Implementation of flipped class room activity on a wider scale however needs careful selection of course objectives and logistics.

An impact on medical student knowledge outcomes after replacing peer lectures with small group discussions

This article was migrated. The article was marked as recommended. Active learning has been proven as an effective teaching method that increases students' academic performance, satisfaction, and promotes life-long learning. A previous study showed that a peer lecture was time-consuming for both faculty members and students without any increase in knowledge outcome achievement of students when comparing to faculty lectures. Therefore, we replaced all peer teachings, taught in 2015, with faculty lectures and small group discussions in an organ-system part which focused mainly on applications of medical microbiology in 2016. The organ-system part was further divided into 3 sections according to type of organ systems. The knowledge outcome achievement was compared using MCQ scores. Peer lectures were mainly used as a teaching method only in 2015 (91.5%, 43 hours from a total of 47 hours) while none of them was used in 2016. On the other hand, SDG were mainly used as a teaching method only in 2016 (73.9%, 51 hours from a total of 69 hours). Students of 2016 had significantly higher average MCQ scores than those of 2015 only in the section 3 (80.8% as compared with 60.5%; p value < 0.001). There was no significant difference in section 1, section 2, and overall MCQ scores. Apart from routine teaching preparation, there was no out-of-class preparation time for faculty lectures and SGD while peer teaching required at least 0.5-2 hours of extra out-of-class preparation time from at least 1 faculty member and 10-12 students per 1 hour of teaching. In conclusion, SGD provided equal or more knowledge outcome achievement of the student with less time-consuming than peer lecture. Therefore, at least in our teaching environment, SGD was proved to be a better option than a peer lecture for teaching applications of medical microbiology.

Flipping the Classroom in Graduate Medical Education: A Systematic Review

BACKGROUND

Flipped classroom (FC) instruction has become increasingly common in graduate medical education (GME).

OBJECTIVE

The purpose of this study was to profile the use of FC in the GME setting and assess the current status of research quality.

METHODS

We conducted a systematic literature search of major health and social science databases from July 2017 to July 2018. Articles were screened to ensure they described use of the FC method in an Accreditation Council for Graduate Medical Education-accredited residency program and included research outcomes. Resulting articles were analyzed, described, and evaluated for research quality using the Kirkpatrick framework and the Medical Education Research Study Quality Instrument (MERSQI).

RESULTS

Twenty-two articles were identified, all of which were recently published. Five were only indirectly related to FC methods. Most studies reported Kirkpatrick-level outcomes. Studies involving resident learner opinions were generally positive. Pre-posttest studies resulted in large positive improvements in knowledge or skills attainment. Control group study results ranged from large positive (1.56) to negative effects (-0.51). Average MERSQI scores of 12.1 (range, 8.5-15.5) were comparable to GME research norms.

CONCLUSIONS

Varying methods for implementing and studying the FC in GME has led to variable results. While residents expressed a positive attitude toward FC learning, shortcomings were reported. Approximately half of the studies comparing the flipped to the traditional classroom reported better achievement under the FC design. As indicated by the MERSQI score, studies captured by this review, on average, were as rigorous as typical research on residency education.