Introduction

Modern health care systems necessitate more efficient, evidence-based methods for teaching in graduate medical education.^1–7 The flipped classroom achieves this by introducing an asynchronous learning experience where learners access basic knowledge at their own pace, preserving face-to-face time with instructors to strengthen advanced concepts through active learning.^8,9

Most studies on the flipped classroom rely on lower-order outcomes, such as descriptive data and learner satisfaction, rather than objective assessments of performance.^10–13 Studies evaluating knowledge are pre-post studies involving a single lecture.^8,12,14–16 More evidence evaluating a comprehensive flipped classroom curriculum with higher-order outcomes is needed,^5,17,18 in addition to testing its efficacy within residency education.^{12–14,16,19–22}

The aim of our study was to compare the knowledge acquisition and retention of the flipped classroom method with that of standard didactic teaching. We hypothesized that the flipped classroom would result in similar satisfaction and knowledge acquisition and would improve knowledge retention.

Methods

Results

Response rates were 63 of 63 (100%) for the preintervention period, 59 of 63 (94%) for the postintervention period, and 36 of 63 (57%) for the delayed postintervention. The average age of participants was 26.9 years, and 41% (26 of 63) were female. Baseline characteristics and performance on the preintervention knowledge test did not differ between the flipped classroom and standard classroom groups (table 1).

table 1 Intern Characteristics in Flipped Classroom Versus Standard Approach^a

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The average preintervention knowledge test score was 51%. Preintervention scores were not significantly different for the 2 groups (51% for both, P > .99). The flipped classroom group performed significantly better than the standard classroom group in unpaired analysis (77% versus 65%; P < .0001; table 2; figure). For the delayed postintervention, the flipped classroom group had significantly higher scores than the standard classroom (70% versus 62%; P = .0007; table 2; figure). These differences also were significant in the paired analysis (table 3).

table 2 Knowledge Acquisition and Retention in Flipped Classroom Versus Standard Classroom Cohorts (Unpaired Analysis)

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table 3 Knowledge Acquisition and Retention in Standard Versus Flipped Classroom Cohorts (Paired Analysis)

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Interns spent more time preparing for the flipped classroom compared with the standard classroom (23 minutes versus 11 minutes; P = .001; table 4). All interns reported high satisfaction with their respective teaching modalities (range of satisfaction scores 4.7–4.9 out of 5).

table 4 Preparation Time and Satisfaction With Learning Experience in Flipped Classroom Versus Standard Classroom Groups

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Interns reported the following barriers towards prework: (1) interference with clinical work (14%, 4 of 29); (2) lack of motivation (7%, 2 of 29); and (3) trouble accessing assignments (10%, 3 of 29). A majority of interns (66%, 19 of 29) felt that the flipped classroom would not be feasible on inpatient rotations. These results are displayed in table 5.

table 5 Intern Attitudes Toward Implementation of the Flipped Classroom^a

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Discussion

In this randomized trial evaluating the flipped classroom within an ambulatory curriculum, we found significant improvement in knowledge acquisition and retention compared with a standard approach in both paired and unpaired analyses. This indicates that the flipped classroom may have achieved the aim of “deep learning.” Learning satisfaction was not compromised, and the additional time commitment was manageable. Our study fills an important gap by evaluating higher-order learning outcomes with a randomized trial in an understudied population.

The finding that learners were satisfied despite increased preparation time with the flipped classroom was encouraging, as time was an important barrier. Restructuring the teaching schedule to provide protected time for prework was likely essential. A noteworthy result was that interns felt that the time barrier would be insurmountable in the inpatient setting. We recognize that an ambulatory teaching schedule, which resembles a “classroom,” more easily permits this teaching method than an unpredictable inpatient schedule does.

This study has limitations, including its scope as a single center study evaluating interns only in the ambulatory environment, which limits generalizability. Using the same instructor for both groups to limit heterogeneity and establish proof of principle represented a potential source of bias and obviated the possibility of blinding. We had a lower response rate for our delayed postintervention measurement, which renders our findings as speculative rather than definitive. Finally, our results do not delineate whether the impact of the flipped classroom derived from the prework or the active learning experience; however, both are considered essential components to implementation of this type of instruction.

Next steps include an expansion of the flipped classroom to the entire ambulatory medicine curriculum. This curriculum includes approximately 900 hours of teaching by 8 faculty members across a large residency program, and it will require faculty development, technological support, and restructuring of the curriculum to implement this teaching approach on a broader scale.

Conclusion

A flipped classroom in a controlled residency setting improved knowledge gain without sacrificing satisfaction or introducing significant time constraints. Residency programs wanting to simulate the principles outlined in this study will need to address the logistical challenges of the flipped classroom related to access and time constraints in addition to providing faculty development to ensure its success.