European Journal of Cardiovascular Medicine

The evolution of medical education necessitates a continuous exploration of innovative pedagogical approaches to equip future physicians with the knowledge and skills required to navigate the complexities of modern healthcare. Traditional didactic lectures, while a long-standing cornerstone of medical curricula, have been increasingly criticised for their passive learning nature and limited effectiveness in fostering deep understanding and long-term knowledge retention. The limitations of didactic lectures include a lack of student engagement, insufficient opportunities for active participation, and a focus on rote memorization rather than the application of knowledge ^[1,2].

In response to these challenges, the flipped classroom model has emerged as a promising alternative. This innovative pedagogical approach inverts the traditional learning structure by shifting the delivery of content to outside the classroom through pre-class materials such as videos, readings, and interactive modules. This allows valuable in-class time to be dedicated to active learning activities that promote deeper understanding, critical thinking, and the development of problem-solving skills ^[3].

The flipped classroom model aligns with established educational theories that emphasise the importance of active learning, self-directed learning, and student-centred instruction ^[4,5]. By encouraging students to engage with course materials independently before class, the flipped classroom model enables them to take ownership of their learning, identify areas of confusion, and come to class prepared for deeper exploration and discussion.

Previous studies have investigated the implementation of the flipped classroom model in various educational contexts, including medical education. While some studies have reported positive outcomes in terms of knowledge acquisition and student satisfaction, others have yielded mixed results, highlighting the need for further research to establish the true effectiveness of this model in medical education [6, 7]. Additionally, the specific impact of the flipped classroom model on different domains of learning, such as factual knowledge, conceptual understanding, and clinical reasoning, remains unclear.

This study aims to address these gaps in the literature by conducting a rigorous randomised controlled trial to compare the flipped classroom model with traditional didactic lectures in medical education. By focusing on knowledge acquisition and student satisfaction, this study seeks to provide a comprehensive assessment of the effectiveness of the flipped classroom model in fostering both academic achievement and a positive learning experience for medical students.

Study Design and Participants

A randomised controlled trial was conducted at Kannur Medical College to evaluate the effectiveness of the flipped classroom model in medical education. A total of 100 second-year medical students were recruited and randomly assigned to either the flipped classroom group (n=50) or the didactic lecture group (n=50). Randomization was performed using a computer-generated sequence to ensure an equal distribution of participants between the two groups.

Inclusion and Exclusion Criteria

Participants were included in the study if they met the following criteria:

• Enrolment in the second year of medical college at Kannur Medical College
• Provision of informed consent to participate in the study

Participants were excluded if they met any of the following criteria:

• Prior exposure to the flipped classroom model in medical education
• Significant cognitive or learning impairments that could affect their ability to participate in the study
• Unwillingness to adhere to the study protocol

Intervention

The flipped classroom group received access to online pre-class materials on the night before each scheduled lecture on circulatory disturbances. These materials included:

• Videos: Concise (5-15 minutes) videos that summarised key concepts required to understand the topic were provided were shared on whatsapp groups. 
• Voice note: a 1–2-minute voice clip containing a brief overview and objective of the forthcoming session was shared on the WhatsApp group.
• Readings: minimal reading material on key concepts that were required to understand the topics were shared with the group.
• Quizzes: To assess understanding and reinforce learning, the students were asked to answer a few questions related to the video and reading material shared.

The didactic classroom group did not receive any of the pre-class materials.

During in-class sessions, both the groups received traditional lectures on the same circulatory disturbances topics. The faculty who took the lectures were unaware of the members in each group. The lectures followed a conventional format with PowerPoint presentations, interspersed with occasional questions and clarifications from students.

Outcome Measures

1. Knowledge Acquisition:
• Multiple-Choice Questions (MCQs): Pre- and post-intervention MCQ tests (20 questions each) were administered to assess factual knowledge and understanding of core concepts in circulatory disturbances. For both the groups, the pre-test was administered before sharing the class material on the previous day and the post test just after the completion of the didactic lecture. The MCQs were designed to cover a broad range of topics and difficulty levels.
2. Student Satisfaction:
• Post-Intervention Survey: A post-intervention survey with a 5-point Likert scale (1= strongly disagree, 5= strongly agree) was used to assess student satisfaction with the learning model. The survey included questions on engagement in learning activities, clarity and organization of instruction, perceived learning, ability to apply knowledge in clinical scenarios, overall satisfaction with the learning model, and suggestions for improvement.

Statistical Analysis

Data analysis was performed using PSPP software. Independent t-tests were used to compare mean pre- and post-intervention test scores and satisfaction scores between the flipped classroom and didactic lecture groups. Chi-squared tests were employed to analyse categorical data (e.g., gender distribution). A p-value of <0.05 was considered statistically significant.

Total of 100 students participated in the study. 66% were females and 34 % were males. 

Figure 1

Figure 2

1. Pre-Intervention Test Scores

Table 1

• T-test statistic: 1.32
• P-value: 0.1903
• Conclusion: There is no statistically significant difference in pre-intervention test scores between the Flipped and Didactic groups.

2. Post-Intervention Test Scores

Table 2

• P-value: 0.0024
• Conclusion: There is a statistically significant difference in post-intervention test scores between the groups. The Flipped group scored significantly higher.

3. Satisfaction Rating

Figure 3

Table 3

• P-value: 0.0000
• Conclusion: There is a statistically significant difference in satisfaction ratings between the groups. The Flipped group reported significantly higher satisfaction.

Figure 4

Males and females in both groups started with similar test scores. Post-intervention, however, the Flipped group showed significantly higher test scores and satisfaction than the Didactic group, regardless of gender.

Overall Conclusion

The flipped classroom method led to significantly higher post-intervention test scores and satisfaction ratings compared to the didactic lecture method. There was no significant difference in pre-intervention test scores, and the distribution of gender was similar between the two groups. The histograms provide a visual representation of the distribution of scores and ratings across the two groups.

The results of this study support the hypothesis that the flipped classroom model is a more effective approach for knowledge acquisition and student satisfaction in medical education compared to traditional didactic lectures. This finding aligns with previous research in other educational settings.

Several factors likely contribute to the enhanced cognitive outcomes, perceived easiness, and improved knowledge recall observed in the flipped classroom group:

• Active Learning: The flipped classroom shifts the focus from passive lecture listening to active engagement with materials. Students actively process information before class, promoting deeper understanding and retention.
• Personalised Learning: The flipped model allows students to learn at their own pace. They can review pre-class materials as many times as needed, focusing on areas where they struggle.
• Increased Interaction: In-class time is dedicated to interactive activities like discussions, problem-solving, and simulations. This fosters critical thinking, collaboration, and application of knowledge.
• Improved Metacognition: The flipped classroom encourages students to reflect on their learning process, identify gaps in understanding, and take ownership of their education.

Pros and Cons from Different Perspectives

Teacher Perspective

• Pros:
• More engaging in-class activities
• Opportunity to address individual student needs
• Increased student-teacher interaction
• Potential for more meaningful feedback
• Cons:
• Requires initial investment in creating pre-class materials
• May not be suitable for all topics or learning styles
• Requires students to be self-motivated and prepared for class

Student Perspective

• Pros:
• Greater control over learning pace
• More interactive and engaging learning environment
• Opportunities for collaboration and peer learning
• Increased confidence and autonomy
• Cons:
• Requires greater time commitment outside of class
• May feel overwhelming for students who prefer traditional lectures
• Requires access to technology and reliable internet connection

Institutional Perspective

• Pros:
• Potential to improve student outcomes and satisfaction
• Aligns with modern educational theories and best practices
• May attract and retain high-quality students
• Cons:
• Requires faculty training and resources to implement effectively
• May need adjustments to curriculum and assessment methods
• Requires institutional support and buy-in from stakeholders

The flipped classroom model is a promising pedagogical approach that has the potential to transform medical education. It is a more effective approach for knowledge acquisition and student satisfaction compared to traditional didactic lectures. Future research should continue to explore the potential benefits of this model.

While the flipped classroom model shows promise in medical education, careful planning and implementation are essential to maximise its benefits. Addressing potential challenges and tailoring the approach to the specific context can help ensure a successful transition from traditional lectures to a more student-centred, active learning environment.

LIMITATIONS OF STUDY

This study has several limitations. The sample size was relatively small, and the study was conducted at a single institution. Future research should replicate this study with a larger and more diverse sample. Additionally, the long-term effects of the flipped classroom model on knowledge retention and clinical performance should be investigated.

Acknowledgements:

We would like to thank the medical students who participated in this study. We would also like to thank the faculty and staff who supported this research.

Disclosures:

The authors declare that they have no conflicting interests.

Glossary:

• Flipped classroom: An instructional strategy in which students engage with pre-class learning materials before attending in-class sessions.
• Didactic lecture: A traditional teaching method in which the instructor presents information to students in a lecture format.

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