The ideal method of resident education is a subject of great interest within the medical community, and many dermatology residency programs utilize a traditional classroom model for didactic training consisting of required textbook reading completed at home and classroom lectures that often include presentations featuring text, dermatology images, and questions throughout the lecture. A second teaching model is known as the flipped, or inverted, classroom. This model moves the didactic material that typically is covered in the classroom into the realm of home study or homework and focuses on application and clarification of the new material in the classroom. 1 There is an emphasis on completing and understanding course material prior to the classroom session. Students are expected to be prepared for the lesson, and the classroom session can include question review and deeper exploration of the topic with a focus on subject mastery. 2
In recent years, the flipped classroom model has been used in elementary education, due in part to the influence of teachers Bergmann and Sams,3 as described in their book Flip Your Classroom: Reach Every Student in Every Class Every Day. More recently, Prober and Khan4 argued for its use in medical education, and this model has been utilized in medical school curricula to teach specialty subjects, including medical dermatology.5
Given the increasing popularity and use of the flipped classroom, the primary objective of this study was to determine if a difference in knowledge acquisition and resident perception exists between the traditional and flipped classrooms. If differences do exist, the secondary aim was to quantify them. We hypothesized that the flipped classroom actively engages residents and would improve both knowledge acquisition and resident sentiment toward the residency program curriculum compared to the traditional model.
The Duke Health (Durham, North Carolina) institutional review board granted approval for this study. All of the dermatology residents from Duke University Medical Center for the 2014-2015 academic year participated in this study. Twelve individual lectures chosen by the dermatology residency program director were included: 6 traditional lectures and 6 flipped lectures. The lectures were paired for similar content.
Each resident was assigned a unique 4-digit numeric code that was unknown to the investigators and recorded at the beginning of each survey. The residents expected flipped lectures for each session and were blinded as to when a traditional lecture and quiz would occur, with the exception of the resident providing the lecture. Classroom presentations were immediately followed by a voluntary survey administered through Qualtrics.6 Consent was given at the beginning of each survey, followed by 10 factual questions and 10 perception questions. The factual questions varied based on the lecture topic and were multiple-choice questions written by the program director, associate program director, and faculty. Each factual question was worth 10 points, and the scaled score for each quiz had a maximum value of 100. The perception questions were developed by the authors (J.H. and A.R.A.) in consultation with a survey methodology expert at the Duke Social Science Research Institute. These questions remained constant across each survey and were descriptive based on standard response scales. The data were extracted from Qualtrics for statistical analysis.
The mean score with the standard deviation for each factual question quiz was calculated and plotted. A generalized linear mixed model was created to study the difference in quiz scores between the 2 classroom models after adjusting for other covariates, including resident, the interaction between resident and class type, quiz time, and the interaction between class type and quiz time. The variable resident was specified as a random variable, and a variance components covariance structure was used. For the perception questions, the frequency and percentage of each answer for a question was counted. Generalized linear mixed models with a Poisson distribution were created to study the difference in answers for each survey question between the 2 curriculum types after adjusting for other covariates, including scores for factual questions, quiz time, and the interaction between class type and quiz time. The variable resident was again specified as a random variable, and a diagonal covariance structure was used. All statistical analyses were carried out using SAS software package version 9.4 (SAS Institute) by the Duke University Department of Biostatistics and Bioinformatics. P<.05 was considered statistically significant.
All 9 of the department’s residents were included and participated in this study. Mean score with standard deviation for each factual quiz is plotted in the Figure. Across all residents, the mean factual quiz score was slightly higher but not statistically significant in the flipped vs traditional classrooms (67.5% vs 65.4%; P=.448)(data not shown). When comparing traditional and flipped factual quiz scores by individual resident, there was not a significant difference in quiz performance (P=.166)(data not shown). However, there was a significant difference in the factual quiz scores among residents for all quizzes (P=.005) as well as a significant difference in performance between each individual quiz over time (P<.001)(data not shown). In the traditional classroom, residents demonstrated a trend in variable performance with each factual quiz. In the flipped classroom, residents also had variable performance, with wide-ranging scores (P=.008)(data not shown).