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Year : 2019  |  Volume : 7  |  Issue : 2  |  Page : 47-50

Flipped classroom as an effective educational tool in teaching surgery for undergraduate students

Department of General Surgery, Karpaga Vinayaga Institue of Medical Sciences, Kanchipuram, Tamil Nadu, India

Date of Web Publication6-Sep-2019

Correspondence Address:
Ramula Durai
A, 14, Old G.S.T. Road, Alagesan Nagar, Chengalpattu, Kanchipuram - 603 001, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_54_18

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Background: In recent years, the flipped classroom (FC) method of teaching has received much attention in health sciences education. The concept of FC has been present in medical education since the 1990s with the introduction of team-based learning. Flipping the classroom is the practice of providing learners with study materials, traditionally covered in lectures, to be learned before class while the teacher becomes the facilitator of classroom discussion. The successful flipped class requires well-planned learning design, interesting study materials, effective plan for formative assessment, to identify gaps in learning, and suitable innovative teaching tools to close the gaps. Although it has been introduced few years back, this concept is new in our institute and we studied this as a pilot project for surgery students. Flipped classroom teaching method elaborated to the students ,before starting this new teaching learning method.
Objective: The objective of the study is to assess the effectiveness of FC teaching in surgery for undergraduate students. Collation of students perception of this new TE-Learning compared to traditional teaching methods.
Methodology: One hundred students of final-year MBBS were included in this study for the surgery subject. Randomly chosen by computer, they were divided into two groups (n = 50). One group followed FC and the other group followed traditional teaching method handled by two different faculties. This study is undertaken to find the effectiveness of FC. Five module were prepared on the topic Groin Hernia “ for this “flipped group” learning. Students in flip group were provided with study materials, videos, and before classroom discussion, while the other group followed didactic lecture. Effectiveness of this new method was assessed by pretest, posttest at the end of the topic, and feedback on perception of flipped class obtained by a questionnaire.
Results: FL group students felt that learning surgery is more interesting and brings in motivation and better understanding of the topic taught. Videos and surgical anatomy were found easy to understand. Eighty-two percent used lecture notes, 62% found PPT easy to follow, while 78% found animation more interesting. In posttest also, flipped group performed better than didactic lecture method. Success depends on the topic chosen, especially in surgery.
Conclusion: Flipped class not only brings motivation but also improves their understanding of the course materials and enhanced their communication skill and clinical thinking. Students in the Flipped Class, showed a preference for this method of teaching and found this more interesting.

Keywords: Didactic lecture, flipped classroom, MBBS, students, surgery

How to cite this article:
Durai R, Mohanraj M. Flipped classroom as an effective educational tool in teaching surgery for undergraduate students. Saudi Surg J 2019;7:47-50

How to cite this URL:
Durai R, Mohanraj M. Flipped classroom as an effective educational tool in teaching surgery for undergraduate students. Saudi Surg J [serial online] 2019 [cited 2022 Dec 9];7:47-50. Available from: https://www.saudisurgj.org/text.asp?2019/7/2/47/266217

  Introduction Top

Flipped classroom (FC) is gaining momentum in medical education, as a method of innovative teaching. FC differs from didactic lectures where the students are made to learn the topic before coming to classroom, and the teacher acts as a facilitator in classroom discussions. There is a paradigm shift in training medical graduates. Competency-based medical education and integrated medical teaching are being introduced in the medical curriculum by the Medical Council of India.[1] Present-day didactic lectures are teacher centric, where students are passive learners as there is no interaction between teachers and students. Teachers are not available after class hours, to clarify any doubts, and students' knowledge is assessed by summative assessment at the end of the year. Mere transferring of knowledge is no longer sufficient; for medical education to be interesting and effective for the students, teaching methods should be more integrated and interactive with scope for formative assessment.[2] FC may address these issues. FCs must be innovative with carefully chosen topics and dedicated faculty to be successful.[3] Problem-based learning or single learning object will make this effective. Flipped classrooms are student oriented as they help the students familiar with topic before classroom teaching. Class discussions become more interactive and the students can have more interactions among peers as well as the teachers.[4] Diversity in learning abilities of students from different background and learning styles requires introduction of innovative teaching methods (TLs). The FC benefits students to obtain background knowledge through study materials and plan of study before a classroom lecture and saves time for applying knowledge discussion facilitated by faculty.[5] The teacher-centric passive learning where there is mere transfer of knowledge is changed to dynamic interactive student-centric classroom.

  Methodology Top

This study was conducted at a teaching hospital, the participants were final-year MBBS students, and the subject chosen was surgery. Source materials such as notes, PPTS and animation videos on surgical anatomy, and surgical techniques were provided 1 week before the class. The same topic taught through e- learning as a part of flipped class, when discussed in classroom later after a week, the teachers role will become just a facilitator for discussion by the students. The didactic lecture group only followed the traditional lectures, with no resource given before the class. The two groups were handled by two different faculties. Both groups were assessed at the end of the topics by formative assessment and impact assessed by feedback from the students.

Data analysis

Collected data were analyzed, and comparison was done using Mann–Whitney U-test. Pre- and posttest scores were compared using independent t-test. Likert scale was used to gather feedback, the mean and standard deviation were calculated to find the perceptions on the effect of flipped learning, and a paired t-test was used to examine the difference in achievement in two groups.

  Results Top

One hundred students for their surgery class were divided into two TL methods (FC and TC) of 50 in each group. Homogeneity was maintained in terms of hours of teaching, and the topic was chosen between the two groups [Table 1]. All students in the FC group received source materials by the faculty in charge. Feedback by way of questionnaire was obtained from both groups. Formative assessment was performed at the end of the class, and a survey on satisfaction levels was conducted to elicit feedback from students on the contents of the class [Figure 1].
Table 1: Demography of students' participation

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Figure 1: Flipped classroom algorithm (Google images)

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[Table 2] perceptions of the students on the two groups showed that more students in the flipped group (84%) felt that they understood the subject better compared to traditional methods (16%). More students in the FC group agreed that their recollection of surgical anatomy and animation videos helped them in their exam preparation (P = 0.012) to understand the course material (P = 0.029) and prepare for the exam (P = 0.001). However, flipped classroom students did not show more satisfaction (P = 0.610) or preference (P = 0.253) for the FC method (P = 0.007). These results suggest that FC approach can enhance students' sense of active participation, interest, and motivation in carefully chosen topics.
Table 2: Students' impact on flipped classroom over traditional classroom based on classroom discussion documented and analyzed

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Bishop and Tucker in their studies on FC felt that it offers flexibility of time, availability of teacher after class hours, retention subjects taught, and more peer interaction. Previous studies have shown that the FC can provide students more flexibility for self-paced learning, help to promote content retention, and promote students' interest in learning. However, Whillier et al. doubted that the FC improves students' performance and satisfaction in learning and felt that the FC may not be suitable for learning memorization-heavy concepts. Therefore, importance should be given to subject and topics for this learning activity.

  Discussion Top

FC is a new method of teaching; and many authors endorse this as an effecting TL method. Since the students are better prepared for classroom discussions, motivation and involvement in the class will be better than traditional methods. Satisfaction, confidence, and performance in exams were also found to be better with this TL.[6] Assessment was mainly centered on the classroom activities or discussions. Since the students are already familiar with the topic through flipped class in advance, it is easier for the students to follow the class and clarify any doubts with the teacher. Assessment can be done in the form of multiple choice questions, quizzes, or focused group discussions. FC should be carefully applied in selected topics. Only suitable subjects can be taught by FC. Content, subject, and dedicated faculty are must for successful implementation.[6] We have no pilot study on this topic but found that the FC model is more effective in teaching surgical topic with applied anatomy. This may be because the source materials are less abstract and more interesting.[7] Tune et al. concluded in their study that FC approach is very effective in medical subjects; Chitz in his experience also felt that it is an overwhelming success. In contrast, Whillier and Lystad felt that there is not much difference between flipped classroom and traditional classroom by way of knowledge or scoring marks.[8] They felt that subjects requiring more memorization may not be ideal for FC teaching. Overburdening the students with preclass workload is not suitable for success of the FC approach. The preclass workload may include a prerecorded video lecture, assigned reading materials, and preparation for in-class presentations and discussion which is just sufficient for class discussion. However, there is no clear suggestion yet in literature on the way or amount of preclass workload.[9] Fen Tang et al. in their study indicated that the average preclass preparation time of 3.5 h triggered student complaints about a workload burden. This FC concept is in nascent stages, at least in developing countries such as India, where the paradigm shift is gradually happening. Further studies may bring more light into subject suitability, and optimal time should be dedicated to the FC approach.[10] FC may be ideal in interactive teaching, where discussions were encouraged and facilitated by the teacher, but falls short in training students in nontechnical skills such as attitude, ethics, and communication.[11] Formative evaluation system for different milestone assessment should be in place for FC to make an impact and help the students to score better. Some authors consider lack of optimization of time and content as some of the drawbacks. Therefore, the core knowledge needed for exam preparation may be diluted by the broad content in student-based discussion even with the control of instructors. Selection of topics, time optimization of content, and carefully planned classroom discussion are crucial to successful implementation.

  Conclusion Top

Flipped classroom allows students to study in their own pace, encourages active engagement of students with lecture material, makes the class room more effective, reflective and interactive with teachers. Literature suggests that this approach helps the students to have sense of control over their learning needs, have positive influence, and stay focused. Students are made to realize their accountability to individual learning which is lacking in traditional teaching which is nothing but mere transfer of knowledge. Many studies have shown that flipped classroom as a new teaching method promote more student involvement than traditional method. The findings from our study also concurred the students preference for the flipped classroom for the reasons that the in flipped classroom e-learning using video material, the opportunity to study in their own pace, flexibility and mobility made learning interesting and more effective than traditional classroom teaching. The faculty also designs the study to cover a wider range of source materials flexibly and according to need. Need-based analysis of the source materials and optimal timing are crucial for this program to be effective.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Medical Council of India. Vision 2015, 2011, Available at http://www.mciindia.org/ tools/announcement/MCI_booklet.pdf. [Last accessed on 2016 Mar 24].  Back to cited text no. 1
Stuart J, Rutherford RJ. Medical student concentration during lectures. Lancet 1978;2:514-6.  Back to cited text no. 2
Fulton K. Upside down and inside out: flip your classroom to improve student learning. Learn Lead Technol 2012;39:12-7.  Back to cited text no. 3
Herreid CF, Schiller NA. Case study: case studies and the flipped classroom. J Coll Sci Teach 2013;42:62-6.  Back to cited text no. 4
Demirören M, Turan S, Öztuna D. Medical students' self-efficacy in problem-based learning and its relationship with self-regulated learning. Med Educ Online 2016;21:30049.  Back to cited text no. 5
Tune JD, Sturek M, Basile DP. Flipped classroom model improves graduate student performance in cardiovascular, respiratory, and renal physiology. Adv Physiol Educ 2013;37:316-20.  Back to cited text no. 6
Chen Y, Wang Y, Chen NS. Is FLIP enough? Or should we use the FLIPPED model instead? Comput Educ 2014;79:16-27.  Back to cited text no. 7
Whillier S, Lystad RP. No differences in grades or level of satisfaction in a flipped classroom for neuroanatomy. J Chiropr Educ 2015;29:127-33.  Back to cited text no. 8
Zappe S, Leicht R, Messner J, Litzinger T, Lee WH. AC 2009-92: “Flipping” the Classroom to Explore Active Learning in a Large Undergraduate Course. Washington: American Society for Engineering Education; 2009.  Back to cited text no. 9
Tolks D, Schäfer C, Raupach T, Kruse L, Sarikas A, Gerhardt-Szép S, et al. An introduction to the inverted/Flipped classroom model in education and advanced training in medicine and in the healthcare professions. GMS J Med Educ 2016;33:Doc46.  Back to cited text no. 10
Strayer JF. How learning in an inverted classroom influences cooperation, innovation and task orientation. Learn Environ Res 2012;15:171-93.  Back to cited text no. 11


  [Figure 1]

  [Table 1], [Table 2]

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