A Debate About the Effectiveness of the Flipped Classroom: Pro

The Flipped Classroom: What is that?

In medical school and post-graduate training, most practicing anesthesiologists and intensivists learned through listening to lectures and reading textbooks. However, modern educational and neurobiological research is showing that these traditional approaches may not be nearly as effective as other modalities of learning. Traditionally, didactics were comprised of experts attempting to transfer knowledge to learners through lectures, a passive event for the learner. Then, learners were supposed to actively apply their new knowledge through assigned homework that was completed outside of class. Enter the Flipped Classroom (FC) model, where that traditional order is flipped, and the new knowledge content that would have been delivered in the lecture is consumed prior to class. Although the pre-class “homework” can take on many forms (i.e. readings, interactive modules, podcasts, etc.), it is most commonly delivered through brief 15-20 minute videos. Precious face-to-face class time is spent in active learning, applying and testing the new knowledge with the expert present to help facilitate the process. This active learning can be done through audience response questions, think-pair-share questions, case based learning, and educational games, just to name a few. In the FC model, the role of the educator changes from the “sage on the stage” to an active facilitator. For anyone beginning to use this method of instruction, it is important to note that the FC includes both the “homework” and the in-class portions of learning.

What are the purported benefits?

There are many suggested benefits of the FC. First, it allows for asynchronous learning, meaning that learners can choose the pace, place, and time in which they learn foundational concepts. Second, learners are more engaged by nature of the problem-solving exercises in class (Sait). Third, the FC model promotes teamwork, which also holds learners accountable to do the “homework” so they are prepared in class. Fourth, the educator has a better opportunity to understand and teach to knowledge gaps as learners are working through problems.

Is there Quantitative Data?

However, these are qualitative outcomes. What about quantifiable results? A number of studies, largely from pharmacy graduate education, demonstrated improvements in knowledge gain and learner preference for FC compared to traditional lectures (Wong, McLaughlin, Pierce). In the setting of undergraduate medical education, there have been mixed results with knowledge and skill acquisition compared to traditional methods, but learners prefer the FC approach. (Chen) Recently, there have been several studies published within graduate medical education (GME). A FAER-sponsored multi-institutional study compared FC to traditional lectures for CA-1 residents preparing for the American Board of Anesthesiology BASIC Examination. There was a trend toward greater knowledge acquisition with the FC at baseline and significantly greater knowledge retention after 4 months compared to traditional lectures. Additionally, the residents preferred the FC model to traditional lectures. (Martinelli JGME) These findings were similar to those reported in a recent study evaluating FC for internal medicine resident quality improvement education. (Bonnes) In addition, a neurosurgery residency program showed an improvement in board scores when FC was utilized. (Girgis)

Most of the FC studies have used multiple choice questions (MCQs) to assess knowledge. As MCQs often fall toward the base of Miller’s pyramid (Miller), this type of assessment may underestimate the value of FC. As one of the goals of active learning and FC is to improve learners ability to problem solve and apply knowledge, it could be posited that this could translate into higher areas of Miller’s pyramid. To test this, Objective Structured Clinical Examinations (OSCEs) were utilized in two prospective controlled studies to assess knowledge application and use of skills in an OB/GYN medical student clerkship (Gillespie) as well as a pharmacy graduate school course (Lockman). Both studies reported significantly greater learning benefits with FC as compared to traditional lectures. This suggests that it might be beneficial for future work on FC in GME to assess with OSCE as well as MCQs.

If the FC is so good, why isn’t everyone using it?

Most of the potential barriers to implementing the FC come from the faculty. Academic anesthesiologists were surveyed about this teaching method and the most common concerns were that: 1) learners would not come to class prepared or participate in class, 2) faculty were more comfortable with lecture-based teaching, 3) it would take too much time to prepare, and 4) the use of technology (e.g. recording a video) was intimidating. (Martinelli JEPM) The experience of programs utilizing FC demonstrate that learners come prepared and are more engaged to learn, train the educator seminars can readily train faculty to be facilitators rather than lecturers, and technology hurdles are minimal and overcome with a short orientation to available resources. Finally, some detractors will note that further research is needed in order to fully demonstrate the efficacy of the FC and to clarify which aspect of active learning is most important. While we agree that future research is needed, the evidence is clear that traditional passive learning through lectures needs to be supplanted with evidence-based methods based on the neurobiology of learning.

In summary, the FC is an emerging and increasingly evidence-based educational method that encourages application of foundational material and problem-solving in the classroom.

  1. Sait MS, Siddiqui Z, Ashraf Y. Advances in medical education and practice: student perceptions of the flipped classroom. Adv Med Educ Pract. 2017; 8:317-320.
  2. Wong TH, Ip EJ, Lopes I, Rajagopalan V. Pharmacy students’ performance and perceptions in a flipped teaching pilot on cardiac arrhythmias. Am J Pharm Educ. 2014; 78(10):185.
  3. McLaughlin JE, Roth MT, Glatt DM, Gharkholonarehe N, Davidson CA, Griffin LM, Esserman DA, Mumper RJ. The flipped classroom: a course redesign to foster learning and engagement in a health professions school. Acad Med. 2014; 89(2): 236-43.
  4. Pierce R, Fox J. Vodcasts and active-learning exercises in a “flipped classroom” model of a renal pharmacotherapy module. Am J Pharm Educ. 2012; 76(10):196.
  5. Chen F, Lui AM, Martinelli SM. A systematic review of the effectiveness of flipped classroom in medical education. Med Educ. 2017; 51(6):585-597.
  6. Martinelli SM, Chen F, DiLorenzo AN, Mayer DC, Fairbanks S, Moran K, Ku C, Mitchell JD, Bowe EA, Royal KD, Hendrickse A, VanDyke K, Trawicki MC, Rankin D, Guldan GJ, Hand W, Gallagher C, Jacob Z, Zvara DA, McEvoy MD, Schell RM. Results of a flipped classroom teaching approach in anesthesiology residents. J Grad Med Educ. 2017; 9(4):485-490.
  7. Bonnes SL, Ratelle JT, Halvorsen AJ, Carter KJ, Hafdahl LT, Wang AT, Mandrekar JN, Oxentenko AS, Beckman TJ, Wittich CM. Flipping the quality improvement classroom in residency education. Acad Med. 2017; 92(1): 101-107.
  8. Girgis F, Miller JP. Implementation of a “flipped classroom” for neurosurgery resident education. Can J Neurol Sci. 2018; 45(1): 76-82.
  9. Miller GE: The assessment of clinical skills/competence/performance. Acad Med. 1990; 65 (9 Suppl): S63-7.
  10. Gillispie V. Using the flipped classroom to bridge the gap to generation Y. Ochsner J. 2016; 16(1):32-36.
  11. Lockman K, Haines ST, McPherson ML. Improved learning outcomes after flipping a therapeutics module: results of a controlled trial. Acad Med. 2017; 92(12): 1786-1793.
  12. Martinelli SM, Chen F, McEvoy MD, Zvara DA, Schell RM. Utilization of the flipped classroom in anesthesiology graduate medical education: an initial survey of faculty beliefs and practices about active learning. J Educ Perioper Med. 2018; 20(1): E617.


Susie Martinelli, MD, FASA
Associate Professor of Anesthesiology
Associate Residency Program Director
Division of Cardiothoracic Anesthesiology
University of North Carolina School of Medicine
Matthew D. McEvoy, MD
Professor of Anesthesiology
Vanderbilt University School of Medicine
Vice-Chair for Educational Affairs
Chief, Perioperative Consult Service
Department of Anesthesiology
Vanderbilt University Medical Center