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J Educ Health Promot
J Educ Health Promot
JEHP
J Edu Health Promot
Journal of Education and Health Promotion
2277-9531
2319-6440
Wolters Kluwer - Medknow India

JEHP-13-283
10.4103/jehp.jehp_1854_23
Original Article
Flipped classroom as an effective educational tool in teaching physiology for first-year undergraduate medical students
Prabhavathi K
KalyaniPraba P
Rohini P
Selvi K Thamarai
Saravanan A
Department of Physiology, SRM Medical College Hospital and Research Centre, SRMIST, Tamil Nadu, India
Address for correspondence: Dr. P Kalyanipraba, Department of Physiology, SRM Medical College Hospital and Research Centre, SRMIST, Kattankulathur - 603 203, Chengelpet, Tamil Nadu, India. E-mail: kalyanip@srmist.edu.in
2024
29 7 2024
13 28312 11 2023
04 3 2024
Copyright: © 2024 Journal of Education and Health Promotion
2024
https://creativecommons.org/licenses/by-nc-sa/4.0/ This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
BACKGROUND:

Flipped classroom (FC) teaching has recently received much attention in medical education. It has been introduced in our institution for 2 years, and we studied the effectiveness and perception of FC teaching in Physiology for first-year undergraduate students.

MATERIALS AND METHODS:

In total, 150 out of 250 first-year MBBS students participated in this study. They were divided into two groups, each consisting of 75 students. Multiple topics in the cardiovascular system were taught to the students by employing traditional classroom (TC) didactic lectures in group A. The same topics were handled using FC in group B, where the students came prepared with the study materials the facilitator provided before class commenced. A well-planned classroom discussion with a formative assessment was conducted at the end. The test scores were compared between the two groups by using an independent t-test. A feedback report was obtained from both groups’ students to analyze the teaching-learning methods’ accomplishment.

RESULT:

FC teaching scores were significantly higher than the traditional lecture among all students. Feedback results showed that 93% of students agreed that the resource materials, group discussions, videos, and exercise tools used in FC were very useful; 95% of students agreed that it provided a good understanding and better appreciation of basic science knowledge in health and disease, and 91% reported that it was well-organized with good interaction, clear explanation, relevant information, and encouraged critical thinking with active student participation.

CONCLUSION:

FC proves to be an effective, interesting, and motivating teaching-learning module. It enhances communication skills, clinical thinking, interaction, and active student participation.

Didactic lecture
flipped classroom
I-year MBBS students
physiology
teaching-learning module
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pmcIntroduction

The medical education system in India for first-year medical students has long been based upon a conventional teaching model that incorporates associating learners in didactic lectures in classroom and laboratory settings. This didactic style of teaching is the earliest and the most famous teaching methodology. This teaching methodology concentrates on teachers providing lessons to learners, generally in the form of lectures in the classroom (Indeed Editorial Team, 2023). As this didactic teaching method is teacher-centric instead of student-centric, the students only perform a passive role of listening and making notes in the classroom, with very less to almost no time available for questioning and interacting, leading to the loss of interest, concentration, and motivation.[1]

In this scenario, there remains a need between the lecturers and learners for a few novel innovational methodologies that could assure additional active engagement of the students as well as the teachers, making the classrooms more interesting, enjoyable, and useful. For enhancing the learning outcome, several novel innovational teaching and learning methodologies such as case-based learning, self-directed learning, design thinking, problem-based learning, flipped classroom (FC), cooperative learning, and concept mapping are being embraced around the globe.

Contemporarily, many educational institutions, especially medical science institutions, successfully implement FC in classrooms to optimize students’ knowledge acquisition and learning outcomes by actively involving them in learning activities. In addition, the competency-based undergraduate curriculum, proffered by the National Medical Council, previously MCI, in 2019, suggested the introduction of FC as a part of training for first-year MBBS students in India.

Physiology remains a complex and arduous subject to study that needs learning, comprehending, and applying several modi operandi to know the functional importance of different organ systems of the human body. For several physiology students, it is difficult to recognize and understand subjects that are taught following the traditional classroom (TC) teaching method in the classroom with deficient learning outcomes. Even though FC was introduced a few years back, this learning methodology has been introduced in SRM Medical College Hospital and Research Center, Kattankulathur, India, only recently. In this scenario, this observational study was conducted to evaluate FC as an effective pedagogical tool than the lecture-based TC methodology in teaching physiology for first-year undergraduate medical students in our institution.

Theoretical underpinning

The FC teaching methodology has gained enormous attention in health sciences education in recent times, although it has remained in practice since the late 1980s (Durai and Mohanraj, 2019). This novel teaching paradigm was first introduced by Militsa Nechkina, a member of the USSR Academy of Pedagogical Sciences, in 1984 (Lowe, 2023).

FC is a type of blended learning strategy in which students finish their reading at home and engage in live problem-solving activities during class time aiming to enhance their participation and engagement in learning (Falciani, 2023). In this method, students are given interesting study materials, which are intended to be learned by them before class, while the teacher turns into the facilitator of classroom discussion and assesses the students at the end with an efficient formative evaluation.[1]

In an FC, learners initially learn about a certain topic by themselves at home either by reading books, watching video clippings, listening to audio recordings, looking at webpages, observing PowerPoint presentations, and so on. Thus, these learners go to their classroom with knowledge about the topic and participate in classroom discussions and activities by being active partakers rather than passive listeners to the teacher’s lectures.

Objectives

The chief objective of this present study was to analyze the positive impact of FC methodology as a pedagogical tool among first-year undergraduate medical students as correlated to the lecture-based TC methodology. Other major objectives were as follows.

To assess the effectiveness of FC teaching in Physiology for first-year MBBS students.

To analyze

(a) If there remains gender difference in this methodology

(b) Whether FC methodology influences low achievers, and

To evaluate students’ perception of this novel teaching-learning methodology.

Materials and Methods

Study design and setting

Observational study, conducted in the Department of Physiology, SRM Medical College Hospital and Research Center, Kattankulathur, India, over a period of 3 months (February–April 2023).

Study participants and sampling

Inclusion parameter

First-year MBBS students in the Department of Physiology who agreed and were present in the class during this study.

Exclusion parameter

Absentees of either lecture class or FC class were excluded from the study. Students who did not give the informed consent form and feedback form were also excluded from the study.

In February, multiple topics on the cardiovascular system, including cardiovascular physiology, properties of cardiac muscle, conducting system, ECG, coronary circulation, and ECG changes in myocardial infarction, were taken as lecture classes for all 250 students. After a 2-month interval, 150 students were selected on a first-cum-first-serve basis. They were split randomly and equally into two groups: group A (TC methodology comprising 75 students) and group B (FC methodology comprising 75 students). In both groups, there were 33 male students and 42 female students. The notion of TC and FC teaching methodologies was described to all the partaking students.

Students in group A were exposed to the TC teaching module, and students in group B were exposed to the FC teaching module on the same topic by the same facilitator. The teaching of this same topic for groups A and B was performed on the same day one by one. For the same, the students of group B were given respective video footage and PowerPoint presentations 2 days before conducting the class. In contrast, the topic was revealed to the students of group A only during the class. Moreover, the students of group B were informed not to reveal the topic to the students of group A before finishing teaching and assessing the learning process between the two groups.

Data collection tool and technique

In light of learning objectives for analyzing students’ knowledge acquisition on the selected topic, a detailed multiple-choice question-based test was modeled for the study. Instantly after finishing the teaching part, the topic associated with knowledge acquisition was evaluated in groups A and B through tests.

A feedback form was given to group A students with the following statements:

(i) Rate the teaching/learning program that comprised transferring knowledge from the teacher to the students through lectures; (ii) Rate the overall teaching program in coronary circulation with regard to (a) understanding the physiology of coronary circulation and its disorders, and (b) appreciation of basic science knowledge in health disease; (iii) Rate your feedback on module organization and delivery concerning (a) module was well organized, (b) facilitator interacted with the student, (c) facilitator gave clear explanations and relevant information, (d) I find the module interesting, (e) facilitator encouraged critical thinking, and (f) facilitator encouraged active participation in the class.

A similar feedback form was given to the students of group B with only the first statement varied, which mentioned

(i) Rate the teaching/learning methods used during the integrated learning program: (a) resources, (b) group discussion, (c) videos, and (d) exercise tools.

The other two statements were the same as in the other feedback form of group A. Each statement was given a 5-scale rating to understand the effectiveness of the teaching methodologies:

indicates “Poor”

indicates “Satisfactory”

indicates “Good”

indicates “Very Good”

indicates “Excellent”

Ethical consideration

Written consent was acquired from every participating student after elaborating on the research’s intention. In addition, the entire study subjects’ anonymity was retained throughout the study. The study was approved by the institutional ethics committee.

Statistical Analysis

A Microsoft Excel spreadsheet was employed for creating the database. Mean ± Standard Deviation (SD) was employed for summarizing the scores. An independent t-test was employed for correlating the scores between group A and group B. Frequency and percentage were stated for the responses of students on TC as well as FC teaching techniques. The P value of < 0.5 was regarded as statistically important, and strata 15.1 was employed for data assessment.

Results

For this study, 150 students were selected and divided into 75 students each in TC group (group A) and FC group (group B).

As can be seen from Table 1, an independent t-test correlating the mean assessment test scores in TC and FC depicted no indication of statistical difference (P > 0.05) between group A and group B. Knowledge acquisition was not affected by the teaching methodologies.

Table 1 Correlation of test score assessment between TC and FC teaching methods

Group	n	Mean	SD	P	
A (TC)	75	6.61	1.941	0.000*	
B (FC)	75	8.17	1.389		

The mean test scores of male students in the TC and FC groups were 6.44 and 8.11, respectively. Female students had test scores of 6.75 and 8.23 in the TC and FC groups, respectively. A comparison of the test scores of male and female students in group A who followed the TC module showed statistical significance with a P value of 0.332 as shown in Figure 1. A comparison of the test scores of male and female students in group B who followed the FC module showed statistical significance with a P value of 0.601. Furthermore, the low achievers of group B in the pre-test showed improvement in their post-test.

Figure 1 Test scores of male and female students in TC and FC modules

Figure 2 illustrates the statistical graph of the feedback report obtained from the students in both groups. In group A, 87% of students termed the teaching/learning methods used during the TC teaching program to be excellent. Furthermore, 85% of students mentioned that they gained a good understanding of the physiology of coronary circulation and its disorders alongside the appreciation of basic science knowledge in health disease. Moreover, 91% of students rated the module’s organization and delivery comprising a well-organized class, good interaction between the facilitator and the students, clear explanations and relevant information given by the facilitator to the students, interesting module, and facilitator encouraging critical thinking and active participation of students to be excellent.

Figure 2 Feedback report of students of groups A and B in TC and FC modules

Furthermore, 93% of group B students rated the teaching/learning methods used during the FC teaching program that comprised resource materials, group discussion, videos, and exercise tools to be excellent; 95% of students stated that they gained a good understanding of the physiology of coronary circulation and its disorders alongside the appreciation of basic science knowledge in health disease. In addition, 91% of students rated the module’s organization and delivery comprising a well-organized class, good interaction between the facilitator and the students, clear explanations and relevant information given by the facilitator to the students, interesting module, and facilitator encouraging critical thinking and active participation of students to be excellent.

The statistical graph illustrated in Figure 2 revealed that the knowledge acquisition was more in FC than in TC as the students in group B had good resource materials, related videos, and exercise tools, and actively participated in group discussions apart from classroom lectures. In addition, the students of group B obtained a better understanding of basic science knowledge in health and disease than the students of group A. However, the students of both groups revealed that both TC and FC programs were well-organized with good interaction with the teacher, who provided clear explanations and relevant information and encouraged critical thinking and active participation of the students. Thus, it is observed that students of group B actively gained more knowledge, interpersonal communication skills, and critical thinking than the students of group A.

Discussion

The present study addressed the correlation of the test assessment score on physiology topic, that is, coronary circulation in myocardial infarction, among the first-year MBBS students split into TC and FC teaching methodologies. Furthermore, for the test score assessment, perception feedback for TC and FC methodologies was obtained from the students.

The healthcare sector, medical treatment, and medicines are modifying and accelerating at a swift rate in terms of content as well as the pertinence of clinical education. Medical education’s target remains to establish and improvise not merely knowledge but also interpersonal and interaction skills and attitude; learning must be an active procedure rather than a passive one in which a teacher’s role should be as a mentor and facilitator to students to provide the best learning environment and learning process.

A similar study by Tang et al. (2017) exhibited that the FC method of teaching-learning is more efficient when compared to the TC method, in agreement with previous studies. As the students come prepared in the FC method, the classroom discussions and students’ engagement in the class are better than the TC method. Satisfaction, confidence, and performance in tests are also observed to be better.[2] Tune et al. (2013) noted that as the students are already familiar with the topic prior to the class in the FC model, it remains easier and simpler for them to follow the class and clarify doubts with the facilitator; moreover, the feedback from the students revealed that they prefer FC teaching-learning module over traditional didactic lecture.[3]

Similarly, Durai and Mohanraj (2019) showcased that students attending FC feel that learning medical science, especially surgery, is more alluring and gain motivation and better comprehension of the topic taught.[4] In addition, the study by Hew and Lo (2018) revealed that the FC method is more motivating for the students to learn when correlated to the TC method.[5] Demirören et al. (2016) found that students consider the FC teaching approach to be more helpful and beneficial for learning the course material and for exam preparation.[6] Furthermore, Tolks et al. (2016) found through their experiment on FC that students in the FC group feel better improvement in their communication and critical thinking skills.[7] A similar study performed by Aggarwal et al. (2019) observed that even though knowledge acquisition is not affected, the students mentioned a great gratification and appreciation for the FC methodology.[1]

Furthermore, Gillispie (2016) concluded in their study that the FC method remains more practicable and beneficial than the TC method for the contemporary generation of students.[8] The study by Banerjee et al. (2019) documented that competency-based medical education incorporating the FC teaching method results in a positive way of learning process among students.[9] In the study carried out by Tang et al. (2017), more students agreed that FC assisted them in accentuating their learning motivation, promoting their comprehension of the course materials, and elevating their communication skills and clinical thinking.[2] Hurtubise et al. (2015) in their study emphasized that FC remains a building block of curricular reformation in medical education as it facilitates teachers to learn regarding competency-based education while retaining promise as a strategy for building bridges across traditional didactic lecture-based curricular boundaries to foster meaningful competency.[10]

Moreover, Phillips and Wiesbauer (2022) emphasized that medical institutions would best serve their students by transforming to an FC model as it adopts digital technology and the enhanced learning advantage by motivating and engaging students.[11] In their study, Veeramani et al. (2015) stated that positive feedback from the students depicted that the FC methodology deserves to be implemented in prospective years.[12] One more study on FC in community medicine by Bogam (2015)[13] observed that there is a substantial change in the learning gain of medical students in FC teaching methodology. This study’s outcome reveals that when students are given accurate and superior quality additional study materials apart from classroom lectures, there remains a great possibility that the students would read the materials prior to the commencement of class. Kühl et al. (2017) highlighted that FC possesses the ability to reinforce self-directed learning, which remains a vital portion of competency-based medical education.[14]

In the current study, authors recognized that communication between the teacher and students was fairly and comparatively better in the FC methodology when compared to the TC methodology. Moreover, the authors observed that FC marked an amplified and intensified knowledge acquisition enhancing students’ interest and active engagement in learning procedures.

Limitation

The active engagement of students in the FC method results in the optimized retention of knowledge acquisition. We analyzed the effect of FC on teaching cardiovascular system topics only, spread over a period of 3 months. In the present study, long-term knowledge acquisition and interpersonal and communication skills attained by students in TC and FC were not analyzed; an analysis like this would be greatly valuable when implemented for multitudinous topics and varied subjects under medical science.

Recommendations

A need-based analysis of the source materials and optimal timing are crucial for the implementation of the FC program to be effective. The following recommendations are suggested to implement the FC method in teaching Clinical Physiology.

Implementation of the FC method in a TC scenario must agree to the requirements and circumstances of the students.

In the transition time, a hybrid amalgamation of TC and FC teaching methodologies could be employed in the classroom until the reception and embracement of novel and innovative FC methodology by the students.

The latest technology-powered learning environment should be incorporated into the FC teaching-learning method to unfold possibilities for the overall advancement of medical students.

The incorporation of the FC approach should aid the ability of students to access resource materials and learn Clinical Physiology anytime and anywhere, and it not only gives a positive result in the examination but also for a long-term learning gain.

Conclusion

The FC approach is a better option than the TC approach in teaching Clinical Physiology. The students are more active, aware, and responsible for their learning process in the FC teaching methodology, which might result in positive and encouraging outcomes in the long term. It turns them to realize their accountability to individual learning, which is lacking in the TC approach, merely transferring knowledge. Furthermore, FC stimulates students’ learning motivation, enhances their performance in their examinations, and assists in optimizing their active participation, clinical thinking, and interpersonal communication skills. In addition, the faculty should design the study to cover a wider range of source materials flexibly and as per the requirements.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The authors gratefully acknowledge the enthusiastic participation of first-year undergraduate medical students of the 2022-2023 batch in the Department of Physiology, SRM Medical College Hospital and Research Centre, Kattankulathur, India.
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