Flipped pedagogical approach in teaching skeletal muscle physiology for undergraduate medical students

INTRODUCTION

The 1^st year of medical education for undergraduate medical students involves teaching-learning sessions that help to establish a strong understanding of physiological principles. Physiology is the foundation of medicine in an undergraduate medical curriculum and has been recognised as a challenging discipline for medical students to comprehend, integrate and apply in clinical sciences.^[1] In the present times, emphasis has been placed on the development of critical thinking skills in contrast to the emphasis on the systems-based didactic lectures. Hence, physiologists are looking for different pedagogic approaches to teaching physiology to undergraduate medical students.

The traditional classroom is a teacher cantered teaching method wherein during the teaching session the content expert presents information about a topic to students and tries to pack as much content as possible in the given time limit. In a traditional classroom, foundational knowledge is passively transferred to students during class through the means of a lecture delivered by content experts.^[2] The students spend most of the time listening to what the content expert tells during the teaching session. Hence, the student’s engagement with the content expert during the session is constrained as there is insufficient time for them to discuss the topic with the faculty member. Hence, the content experts try to imbibe newer teaching-learning approaches in attempting to make the learning process more engaging.

The flipped classroom (FC) is a type of instructional approach that encourages higher-order thinking and active participation from students.^[3] The FC is changing the face of teaching across the world in higher education. The utilisation of the FC teaching method in teaching medical students was first demonstrated and published lately.^[4] In the current years, educators encircle FC as it is a student-centered teaching method. In this method, students are subjected to teaching materials in the structure of short videos, PowerPoint slides, and assignments earlier to the class, and during the class the session is structured to encompass short lecture review sessions where students are provided a favourable circumstance to raise a question and get occupied with the content expert. After the review session, the content expert can conduct learning activities like short medical cases related to the topic, quizzes, and small group discussions which will help students to acquire a better understanding of the content in comparison with learning through traditional teaching methods.

It is suggested that the FC actively encourages the incorporation of independent learning and use of technology outside the classroom and student-centered activities^[5] and more organised student-teacher interactions inside the classroom.^[6] Hence, the study was conducted with the objectives to assess the test scores of the participating 1^st-year MBBS students after an FC session on a topic in skeletal muscle physiology (using a pre-test and post-test) and to compare these scores with the test scores after traditional classroom teaching session on a topic in skeletal muscle physiology (using a pre-test and post-test) and to assess the students’ appreciation toward the FC teaching method using a semi-structured peer validated feedback questionnaire.

MATERIALS AND METHODS

After obtaining permission from the Institutional Ethics Committee, the objectives of the study were explained to ^1st-year medical students, who were enrolled in the Bachelor of Medicine, Bachelor of Surgery (MBBS) course in a private medical school. Twenty-one 1^st year medical students agreed to participate in this study by giving written consent. In the MBBS curriculum, skeletal muscle physiology is covered in three lectures. One of the lectures was flipped and the other two lectures were conducted in traditional format. All 28 students attended both flipped and traditional format lectures.

Flow chart showing the study design for traditional versus flipped classroom

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RESULTS

In the present study, out of 28 1^st year undergraduate MBBS students, seven students did not give post-test due to absenteeism for varied reasons. Hence, they were excluded from study and data analysis was done for 21 students. All the cohorts (n = 21) involved in the study were taught by the same faculty for both flipped and traditional classroom sessions and the pre-and post-tests questions were same for both the sessions. This is done to ensure and rule out the consequences, if any, of confounding variables.

Student feedback on FC

In the present study, 79.6% agreed that they watched all the assigned videos before coming to the FC [Figure 1]. Majority of the students agreed that the interactive applied in class activities and in-class discussions of the course concepts with peers during FC enhanced their learning. About 78.5% of the students agreed that FC was an enjoyable way of learning [Figure 1].

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Figure 1:

Students’ perception about flipped classroom.

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DISCUSSION

This study was designed to evaluate the effectiveness of FC versus traditional classrooms in teaching skeletal muscle physiology to 1^st-year MBBS students.

In our study, the pre-test mean score was higher for FC (5.48 ± 1.44) when compared to the traditional classroom (3.19 ± 1.4) [Table 1]. In a study conducted among 95 4^th-year students enrolled in the ophthalmology clerkship, there were no differences between the FC group and traditional lecture-based classrooms with regard to their pre-test scores, but the post-test showed that students in the FC group had significantly higher scores than those from the traditional lecture-based classroom.^[7]

The scores from pre-test to post-test in a traditional classroom showed statistically significant improvement but not in the FC [Table 1]. A traditional classroom is a passive learning method and students have minimal knowledge about the topic prior to the classroom session. The power-point slides were designed to help students to prepare for the pre-test and the lecture but power-point slides without a video did not stimulate any interest among our students which resulted in a decrease in the pre-test score. The results show that the traditional passive teaching approach has a positive impact on student cognitive outcomes. But in a study conducted at a medical college in India among medical students about knowledge of participants about various components of the National Vector Borne Disease Control Program statistically significant improvement in knowledge from pre-and post-intervention because of the ‘Flipped Teaching Model’ was reported.^[8] Tune et al. also reported statistically significant improvement in knowledge of medical students about cardiovascular, respiratory, and renal physiology with flipped teaching methodology when compared to traditional teaching methodology.^[9] In a study conducted in India among 150 1^st year medical students, there is statistically significant post-test score in FC method compared to traditional classroom method, concluding FC method improves teaching-learning outcome compared to traditional method^[10] which contrasts with the findings observed in our study.

In the FC, the mean scores in question number 2, 3 and 5 showed an improvement in score between pre and post-tests but only the difference between mean correct responses for question number 5 (P = 0.031) was statistically significant [Table 2]. In the traditional classroom, there was improvement in the mean scores in all the eight questions between pre-test and post-tests but the mean scores of question numbers 5 (P = 0.031), 6 (P = 0.031) and 7 (P = 0.008) in pre-test and post-test were statistically significant [Table 3]. This shows lack of pre class preparedness among students in a traditional classroom format when compared to the FC format and the effectiveness of passive traditional teaching method. The post-test scores between a FC and traditional classroom were not statistically significant [Table 4]. This indicates that traditional and FC pedagogical approaches cause equal retention of knowledge.

In our study, 79.6% of students agreed that they watched all the assigned video and 78.6% of students completed reading the assigned power-point presentation slides before coming to the FC [Figure 1]. Short videos which present information to students makes learning easier for students and strengthen their concepts. About 78.5% agreed to learn more topics in FC format [Figure 1]. Christopher and Pound studies said medical students have generally expressed strong satisfaction with early applications of the FC to undergraduate medical education and generally prefer this method to lecture-based instruction.^[11]

When queried if FC was more engaging and interesting in comparison to traditional class, 78.6% of students agreed [Figure 1]. This is consistent with the study which was conducted among 1^st-year undergraduate medical students where students’ enjoyment during class hours, interaction and learning process in FC method was more compared to the traditional method.^[10] In our study, when students were enquired about various factors which enhanced their learning 89.2% students agreed that interactive, applied in class activities enhanced their learning, 89.3% agreed that in class discussions of the course concepts with my peers enhanced my learning and 89.3% agreed to that the activities during FC session improved their understanding of the key concepts. It is a fact already known that the strategy of FC is to provide students an opportunity to apply what they have learned prior to class and this is well documented from the student feedback when they were asked about various factors that enhance their learning. In the FC, the in-class activity involves discussions over the assigned topic and application-based learning activities which are based on the study materials provided earlier. In a study conducted among students undergoing a basic-science course in the 1^st-year curriculum which covered basic neuroscience, neuroanatomy, histology, and systems physiology, the majority of students felt that the FC better helped them increase their analytical thinking (58.5%) and problem-solving skills (61.5%) compared to the traditional classroom.^[12]

CONCLUSION

Our findings suggest that flipped pedagogical approach and traditional teaching approach are both effective means of teaching undergraduate medical students.

Limitations

Limitations of the present study were that it was conducted on only one batch of MBBS cohort and only to skeletal muscle physiology topics.