Central Journal of Family Medicine & Community Health

Cite this article: Jump C, Sahn B, Wendel D, Augustine M, Fish S, et al. (2017) Using Fellows to Implement a ‘Flipped Classroom’ on an Inpatient Pediatric Rotation. J Family Med Community Health 4(3): 1112.

Abstract

Aim: The ‘flipped classroom’ is a type of inverted learning where students are able to have a first-exposure of the proposed topic prior to the formal education setting. We aimed to implement a novel and sustainable approach using a ‘flipped classroom’ model to provide residents an improve learning experience that complies with their schedule restrictions while utilizing pediatric subspecialty fellows as teachers.

Method: Video presentations were developed for 5 topics: constipation, diarrhea, vomiting, failure to thrive, and neonatal cholestasis. The videos followed a standardized format, including: definitions, pathophysiology, differential diagnosis, evaluation, ‘red flags’, and treatments. Residents on the gastroenterology service participated in a thirty-minute teaching session by a GI fellow, with the expectation that they would view the topic video prior to a session.

Results: A total of 18 residents participated in this intervention. Of the residents who watched the videos, all believed the video added to their knowledge base and 70% felt that watching the video improved the subsequent teaching session. The sessions were rated as highly interactive by all learners with 87% citing it as an improvement from other formats.

Conclusion: Implementation of the ‘flipped classroom’ learning format for residents on an inpatient rotation by pediatric gastroenterology fellows provides structure to the teaching sessions, added to the knowledge base of residents, was enjoyable, and allowed fellows to develop skills as teachers.

*Corresponding authorHenry Lin, Department of Pediatrics, The Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Philadelphia, PA, USA, Tel: 215-590-7801; Fax: 215-590-3606; Email:

Submitted: 05 May 2017

Accepted: 30 May 2017

Published: 01 June 2017

ISSN: 2379-0547

Copyright© 2017 Lin et al.

OPEN ACCESS

Keywords•Adult learning•Fellows as teachers•Flipped classroom•Graduate medical education

Research Article

Using Fellows to Implement a ‘Flipped Classroom’ on an Inpatient Pediatric RotationCandi Jump1, Benjamin Sahn2, Danielle Wendel2, Marianne Augustine2, Samantha Fish2, Lindsey Albenberg2, and Henry Lin2*1Department of Pediatrics, Medical University of South Carolina, USA2Department of Pediatrics, The Children’s Hospital of Philadelphia, USA

INTRODUCTIONBetween resident responsibilities and resident work hour

restrictions, providing quality graduate medical education during resident rotations can be a challenge, specifically with regards to finding ideal teaching methods. The goals of duty hour restrictions were to improve patient safety, resident well-being, and education [1], but may have translated into a shift towards more service and less education [2]. A 2011 survey on resident perceptions of education found that compared to the traditional every fourth night call, residents on a shift schedule rated the amount and quality of education they received less favorably [3]. With the time allotted to didactic teaching dwindling, structured education must evolve and become a more efficient practice.

The ‘flipped classroom’ is an inverted learning experience where students have a first-exposure of the proposed topic prior to the formal education setting. Dedicated teaching or class time is used to assimilate the knowledge. The first exposure is most often a video presentation to be viewed on the students’ own time as having background knowledge on subject matter

enhances the in-classroom experience.This contrasts with the traditional model which emphasizes a didactic format, where by the residents are taught through a lecture or case presentation often without significant knowledge of the topic prior to the lecture [4]. With the ‘flipped classroom’ approach, the facilitator can use the limited classroom time for ascending the cognitive hierarchy to applying, analyzing, evaluating, and creating [5,6].

In medical school, the majority of didactic learning occurs within the non-clinical first two years. Application and analysis are deferred to the third and fourth clinical years of education. By convention, this puts an aperture between the acquisition of knowledge and the application of that knowledge. Residency and fellowship programs replace basic science and physiology with diagnostic criteria and treatment algorithms. Flipping the classroom in graduate medical education can help learners review basic principles ahead of time so that learners can capitalize on the expertise of their teachers during classroom time.

At the Children’s Hospital of Philadelphia (CHOP), a tertiary care academic center, resident feedback identified the need to

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improve the quality of resident education during the inpatient pediatric gastroenterology (GI) rotation. During this rotation, time for structured didactics was limited. Senior pediatric GI fellows attempted to deliver lectures to the residents, but the quality and quantity of these sessions were highly variable. In response, a novel and sustainable education approach was implemented using the ‘flipped classroom’ model to provide residents an improved learning experience that complies with their schedule restrictions while utilizing pediatric subspecialty fellows as teachers.

MATERIALS AND METHODS Module development

Senior GI clinical fellows developed lessons for five topics: constipation, diarrhea, vomiting, failure to thrive, and neonatal cholestasis. These topics were chosen after a preliminary survey was circulated to residents asking which gastroenterology topics were important for the primary care pediatrician. For each of the five topics fellows created two presentations: one for a web-based video and another for a corresponding live case-based module. The presentations followed a standardized format, including: definitions, pathophysiology, differential diagnosis, evaluation, “red flags,” and treatments. These presentations were imported into the iPad application Explain Everything (EE) (Morris Cooke and Constructivist Toolkit LLC 2013) to create the videos. The video can be uploaded to YouTube, camera roll, or any online storage website and viewed by learners both remotely and asynchronously, which allows for the presentation to be watched prior to the on-site learning.

The case-based modules consisted of 3-5 multiple choice questions adapted from published board review sources, either by the American Academy of Pediatrics or the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Answers for questions were provided as well as discussion points.

Participants

Residents rotating through the inpatient gastroenterology service at CHOP participated in this intervention. The learners were categorical pediatric level 2 residents. All teaching was performed by senior GI fellows.

Implementation

During a four-week resident rotation, three core topics were covered during each rotation. The residents were surveyed at the start of the rotation to identify topics of interest. Links to the videos were distributed to the residents with the expectation that residents would independently view the video prior to the teaching session. The 30-minute teaching session occurred prior to the start of inpatient rounds. GI fellows utilized the established case-based presentations to facilitate discussion and encourage interactive teaching.

Evaluation

Each study participant completed a questionnaire prior to the first ‘flipped classroom’ session and at the end of the last session.

Ethics

In review by the Children’s Hospital of Philadelphia’s Institutional Review Board (IRB), the study qualified as exempt from IRB. For study participants, verbal consent was obtained at the time of the survey. Participation in this study was optional and participants had the option to opt out at any time.

RESULTS AND DISCUSSIONThe flipped classroom model was implemented during the

2014 academic year. A total of 18 residents participated in this program, with each participant attending at least 3 educational sessions.

Pre-intervention survey

The majority (61%) of the residents thought that 30 minutes is the ideal amount of time for educational activities and that case based presentations (55%), patient rounds (39%), and the ‘flipped classroom’ (7%) were ideal settings. No residents chose a traditional lecture setting as ideal. The optimal timing for the learning session was thought to be before rounds (55%) or in the afternoon (39%). The majority of our learners (72%) felt they received enough teaching during their previous inpatient GI rotation.

Post-intervention survey

Over half (63%) of the participants watched at least some of the videos (Figure 1), but many (56%) found it difficult to watch the videos because of a shortage of time. Of the residents who watched the videos, all believed the video added to their knowledge base and 70% stated that watching the video improved the quality of the subsequent teaching session. The new learning format was considered an improvement from the previous year’s education sessions by 87% of the participants, regardless of whether the videos were watched (Figure 2). 57% of learners believed that the fellows taught better under the ‘flipped classroom’ format. The sessions were rated as highly interactive by all learners. After being exposed to the ‘flipped classroom’ model, the participants similarly preferred case-based learning (44%) and the ‘flipped classroom’ format (38%) compared to teaching on rounds (6%) and lectures (0%) (Figure 3).

Discussion

In this pilot study, the‘flipped classroom’ model was shown to be an efficient and effective way to enhance the resident education experience. Part of this improvement in the teaching session could be attributed to using an approach that is more conducive to adult learning as there are multiple studies on the limitations of didactics as an effective adult learning mechanism, regardless of learning style. The ‘flipped classroom’ is a new pedagogical method, which employs asynchronous learning activities prior to the in-classroom experience. Digital media allows educators to create video tutorials relatively easy and offers flexibility so that learners can watch on their own schedule and at their own pace. Learners enter a live interactive session with strengthened background knowledge, which enhances their experience and the facilitator can use classroom time for ascending the cognitive hierarchy to applying, analyzing, evaluating, and creating [5]. With the ‘flipped classroom’ approach, any questions about

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Watched All

Videos, 13%

Watched Some Videos,

50%

Did not watch videos, 37%

Figure 1 Percentage of residents whom watched all, some, or none of the flipped classroom videos.

Statement Strongly Disagree

(n%)

Disagree(n%)

Neutral(n%)

Agree(n%)

Strongly Agree(n%)

1 0 0 13 56 31

2 0 0 0 44 56

3 0 0 6 56 38

4 0 0 40 46 14

Figure 2 Post-survey resultsStatement

1. The value of this block’s sessions, given the new format, is greater than previous sessions with the GI fellows. 2. The sessions are highly interactive.3. The topics available for the sessions are appropriate for my level of education.4. The fellows do a better job of teaching residents using the ‘flipped classroom’.

44%

6%

39%

0% 0%

43%38%

6%0%

12%

0%

10%

20%

30%

40%

50%

Cased Based Presentation

Flipped Classroom Teaching on Rounds

Lecture No Answer

Pre-Survey Post-Survey

Figure 3 Resident preferred learning setting before (pre-survey) and after (post-survey) exposure to flipped classroom.

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foundation material can be entertained before the interactive portion of learning.

During an inpatient rotation, time for structured didactics is often limited and dependent on many factors including prioritization of patient care, inpatient volume, faculty on service, and resident availability. Resident education can thus be unstructured and innovative strategies are needed to deliver quality teaching. The ‘flipped classroom’ provides an ideal approach to didactics which capitalizes on the limited availability of the students and teacher. In this pilot study, the ‘flipped classroom’ was well received by the residents and the sessions were unanimously favored over the previous traditional didactic format. This improved resident satisfaction could be due to the interactive nature of the ‘flipped classroom’ which facilitates learner engagement. The standardized teaching format at a level appropriate for the learner’s expertise may have also contributed to satisfaction. In addition, the 30 minute sessions were the ideal length for resident attention as identified by initial survey.

One challenge encountered with implementation of the ‘flipped classroom’ was the inconsistent viewing of the videos prior to teaching sessions. The videos ranged from 8 to 12 minutes in length so it is unlikely that video length was problematic. Even with restricting the length of the videos, almost half of the residents found it ‘difficult to find time to watch the videos’. It is possible that residents encountered barriers to video access in the method of distribution, but the video link wasemailed to the learners.Lack of interest in the educational topics could also limit video utilization. However, the modules were designed in response to a resident survey on gastroenterology topics that they believed to be important for a general pediatrician. Some residents may have felt that the educational yield of the videos would not be high enough to make their viewing a priority, but the post-intervention survey indicated that the residents who watched the videos all believed it added to their knowledge base. Regardless of reason, pre-discussion preparation is an integral part of the ‘flipped classroom’ approach and garnering full resident participation will help improve the quality of education.

One unintended, but positive outcome of the ‘flipped classroom’ was its utility as a scaffold for fellows teaching. Previous studies have suggested that in large tertiary care academic centers, fellows may dilute the educational experience for residents [7]. However, requirements to increase scholarly productivity and maintain a high level of clinical care can limit attending physician availability for structured didactics and provides an opportunity for fellows to teach [8]. For fellows who pursue a career in academic medicine, teaching is often part of their clinical duties, but there are currently limited formal training opportunities for developing fellows as teachers. With the majority of the pediatric GI workforce employed in an academic setting, many graduating fellows will need to be competent teachers to be successful in their future careers [9]. A 2007 survey of graduating GI fellows showed, on average, that fellows felt competent in delivering case-based teaching in a hospital setting, however only delivered between 11-20 formal lectures during their training. Therefore, a premium exists on developing young physician educators with skills in teaching adult learners.

In the pilot study, residents perceived that GI fellows

improved as teachers. With the ‘flipped classroom’, fellows prepare for teaching by developing the content and then leading the case discussion as part of the interactive session. With the current approach, clinical fellows will have delivered between 12-24 ‘flipped classroom’ sessions alone during their senior years of fellowship [10]. This increased exposure will allow fellows to improve their self-assessed competence to a measurable proficiency in delivering didactics to residents prior to graduation.

One limitation of this study is the lack of data regarding knowledge acquisition. The goal of education is knowledge retention and a pre-and post-learning session knowledge assessment could allow for such analysis. Due to the aforementioned limitations on time, it was challenging to find an ideal time to administer the assessment. Also, it is difficult to measure the effect of this particular intervention from ongoing interventions such as knowledge gained from other sources during their GI rotation. There is also a paucity of data on the previous intervention, the traditional didactic approach, for comparison.

CONCLUSIONTo the authors’ knowledge, this is the first report of flipped

classroom utilization in pediatric subspecialty residency education. Implementation of the ‘flipped classroom’ learning format for residents on an inpatient rotation by pediatric gastroenterology fellows was successful. The new format provides structure to the teaching sessions and added to the knowledge base of residents. Pediatric subspecialty fellows possess a unique knowledge base and should be involved in resident teaching and the flipped classroom provides an opportunity to build fellow’s skills and confidence as teachers. Future directions of this pilot study include expanding the number of core topics provided to residents and developing video modules more suited for other learners such as nurses and medical students assigned to the GI inpatient service.

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Cite this article

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