Using design-based research to aid the development of a case-directed learning pedagogy for the preclerkship medical curriculum.

University of Virginia School of Medicine

Background First-year medical students may find it challenging to integrate complex physiological concepts, particularly neuromuscular physiology. While concept mapping has shown promise in medical education, its specific application in teaching intricate physiological mechanisms still needs to be explored. With this background, the objective of the study was toassess the feasibilityof using concept mapping among first-year medical students and to explore the perception of students about concept mapping as an educational tool. Methods A mixed-methods study was conducted with first-year medical students (n = 110) of the 2023-2024 batch at All India Institute of Medical Sciences, Bhubaneswar, India. A briefing on the basic theories of concept mapping was carried out. Students participated in a structured concept mapping session focusing on the mechanism of muscle contraction. Students (two students in a group) created concept maps illustrating relationships between neuronal architecture, action potentials, neuromuscular transmission, sarcotubular system, excitation-contraction coupling, and muscle contraction processes. Data collection included digital submissions of concept maps and structured feedback questionnaires. Two faculty members evaluated the concept maps, and student feedback was analyzed using quantitative and qualitative approaches. Results A total of 110 first-year undergraduate medical students participated in the study and created 55 concept maps. The students scored 17.32 ± 1.7 out of 20 maximum achievable scores, which corresponds to an average of 86.59%. Seventy-five (68.18%) students rated the technique as excellent, 32 (29.09%) found it good, and only three (2.73%) rated it as average. Ninety-eight (88.8%) students strongly agreed or agreed that it provided a practical learning experience and found it refreshing compared to traditional lectures. Additionally, 102 (92.7%) students acknowledged its ability to stimulate creative thinking, and 102 (92.7%) also reported effective collaboration with peers. According to 82 (74.5%)students, concept mapping also facilitated in-depth knowledge acquisition, demonstrating its effectiveness in promoting active, engaging, and collaborative learning. Qualitative analysis revealed that concept mapping helped the students organize complex information, encourage critical thinking, improve retention through visual learning, promote collaborative knowledge-building, and facilitate self-assessment of their understanding. Conclusion Concept mapping can be used as apedagogical tool for teaching complex neuromuscular physiology concepts to first-year medical students. The technique can bridge the gap between fragmented knowledge and integrated understanding while promoting active learning and critical thinking. The majority of the students rated it as excellent or good. It significantly enhances engagement, creative thinking, and deeper subject understanding compared to traditional lectures. Qualitative feedback underscores its role in improving comprehension of complex concepts and critical thinking skills.

Rutgers Robert Wood Johnson Medical School.

Texas A&M University College of Medicine.

Northern Ontario School of Medicine

The University of Kansas School of Medicine.

University of Massachusetts Medical School

University of New Mexico School of Medicine

Introduction: Acquiring knowledge and skills is a lifelong process for medical professionals, emphasizing constant self-update for better medical education & patient care (1). Teaching systems have evolved to enhance higher cognitive learning among undergraduates. Self-Directed Learning (SDL), introduced by Knowles in 1975, empowers students to diagnose learning needs, set goals, identify resources, & evaluate outcomes, inculcating curiosity, critical thinking, & problem-solving (2). However, SDL relies on student motivation & awareness which in turn are influenced by multiple other factors. The SRSSDL Tool evaluates readiness and identifies support areas which require support and shape themselves to adapt for better learning (3). This study assessed SDL’s efficacy and influencing factors among undergraduates. Methods: This study was performed on first-year medical students (n = 149) which was initiated four weeks before the session, with pre-reading materials shared two weeks earlier. The topic chosen for SDL was competency 4.1: " Structure and Function of Digestive System ". On the session day, students were divided into 10 groups. The students were divided randomly and team members list was distributed along with the pre-reading materials. The individual (iRAT) and team (tRAT) readiness assurance tests were conducted for 10 minutes, followed by 10-minute discussion. Then teams addressed Short Answer Questions (SAQs) for 20 minutes, followed by 10 mins discussion. The groups created questions, exchanged, and solved them within 15 minutes, presenting their answers in another 15-minute discussion. The session concluded with a summary (10 minutes). Attitudes and readiness were assessed using SRSSDL, followed by feedback (5-point Likert scale: audiovisual aids, teacher interaction, conduct of the session and session closure). The formative assessment was conducted after two weeks of SDL session, covering all topics taught during the preceding four weeks. Result: A total of 124 students (82.7%) participated in the SDL session. The iRAT and tRAT each comprised five questions, with mean scores of 4.8 and 5, respectively. Teams scored 83% on SAQs. Question framing was assessed based on objectivity, specificity, and cognitive load, scoring the mean score of 3.4 out of 5, while answers discussed scored 4.2 out of 5. The overall feedback is as follows: rating of 5 (68.05%), 4 (26.4%), 3 (3.15%) and 2 or 1 (2.4%). The positive correlation of feedback with components of SRSSDL tool (self-awareness, strategies and evaluation) is significant. A 1.5 fold improvement in formative assessment scores for SDL topics compared to traditional lectures highlighted the session’s efficacy. The components of SRSSDL tool (self-awareness, strategies and evaluation) is positively correlated with the scores in formative assessment. Conclusion: SDL effectively promotes engagement, better outcomes, and essential skills in first-year medical students. It fosters self-awareness, critical thinking, and collaboration, aligning with educational needs. Feedback confirms SDL's value in enhancing preparedness for self-guided learning. Integrating SDL with traditional methods in medical curricula can significantly improve student performance and readiness for the evolving demands of medical practice.

Loma Linda University School of Medicine.

prevalent in 20–57% of stroke patients, visual field defects have been shown to impact quality of life. Studies ([8][1]) have shown increased risk of falling, ambulatory difficulties, impaired reading ability, and feelings of panic in crowded or unfamiliar places in patients with visual field

Curriculum Management and Governance Structure ♦ The Committee on Curriculum and Academic Policy (CCAP) is a standing committee of the School of Medicine Faculty Senate and is chaired by the Associate Dean for Medical Education. ♦ CCAP develops or recommends policies concerning the curriculum for the MD degree program, including the structure of the curriculum and requirements for graduation, design and evaluation of courses and clerkships, adherence to Liaison Committee on Medical Education (LCME) guidelines, and evaluation of program effectiveness. ♦ CCAP oversees the assessment of medical student academic performance in required courses, clerkships, and scholarly concentrations. ♦ CCAP advises and recommends to the Faculty Senate changes in academic policy that affect performance assessment and advising and also reviews and advises the Dean's Office on the format and content of the Medical Student Performance Evaluation (MSPE). ♦ CCAP also reviews and approves requests for new required courses and clerkships (core and selective). ♦ The standing committees of CCAP that provide advice and input to CCAP on curriculum management and policy issues are as follows: Pre-Clerkship Course Directors Clerkship Directors Clerkship Evaluation Committee Office of Education ♦ The Office of Medical Education (OME) has primary responsibility for the MD program. ♦ The office is led by the Associate Dean for Medical Education, who has direct responsibility for the curriculum and its core faculty leaders, and the Assistant Dean for Medical Education, who manages the staff, finances, and operations and assists with curriculum management (Figure 1).FIGURE 1:: Office of Medical Education♦ The Office of Medical Education reports to the Senior Associate Dean for Education, who has a broader leadership role within the School of Medicine that includes undergraduate medical education, graduate medical education, and continuing medical education. ♦ In addition to the Associate Dean for Medical Education, eight faculty provide leadership, on a part-time basis, for core educational programs within the MD program, including the Preclerkship Curriculum; Clerkship Program; Educators-4-CARE; Scholarly Concentrations; Standardized Patient Program; and the Research, Reflections and Advances in Patient Care Curriculum. ♦ In addition to the Assistant Dean for Medical Education, there are nine full-time staff and one part-time staff who support the MD educational programs as listed previously. In addition, two full-time staff direct and support the Division of Evaluation, which oversees the evaluation of required courses and clerkships. Financial Management of Educational Programs ♦ During the current financial crisis, emphasis has been placed on reducing nonessential operational costs in order to retain the FTE necessary to continue delivery and improvement of the curriculum. Another goal has been to retain sufficient operational funds in order to maintain the quality of education for students. Nonessential travel and food/entertainment expenditures have been among the key areas for cost reduction. Valuing Teaching ♦ In 2008, Stanford established the “Educators-4-CARE” (E4C) program. E4C is a program in which we carefully select 15 faculty recognized for compassion, humanism, and excellence in teaching to serve as small group teachers and mentors for six students each, beginning at matriculation and lasting until graduation. ♦ The program embodies a commitment to Compassion, Advocacy, Responsibility, and Empathy. Although beyond this there is currently no formal academy/institute at Stanford for educators, an effort is currently under way to review how the promotion and tenure process could be adjusted to more directly value teaching. ♦ The Teaching Excellence Task Force was created in 2009 and is currently at work on addressing these issues, including evaluation of teaching, award/recognition of excellence in teaching, and optimal allocation of education funding to best support teaching. ♦ Excellence in teaching is currently recognized through a variety of teaching awards, the recipients of which are selected by students. In addition, key education leaders and nominees for teaching awards are annually acknowledged for their contributions. ♦ New and enhanced faculty development initiatives are currently in development. Curriculum Renewal Process ♦ Curriculum renewal began in 2002, with the following goals: early and substantive instruction in clinical skills integration streamlined content and optimized course sequence melding basic science and clinical concepts blocks of unscheduled time for study, electives, research option of a fifth or sixth year of study, dual degrees scholarly concentrations mentored opportunity for scholarly work in selection of thematic areas Learning Outcomes/Competencies ♦ A reexamination and update of competencies will be launched in 2010. ♦ Current competencies are listed on the following website: http://med.stanford.edu/md/competencies.html. New Topics in the Curriculum Since 2000 ♦ Patient safety: introduced in 2010 (preclerkship curriculum) ♦ Quality improvement: introduced in 2010 (preclerkship curriculum) ♦ Team-based learning: introduced in 2007 (preclerkship curriculum) ♦ Simulations/training in new surgical techniques: introduced in 2004 (preclerkship curriculum and selected clerkships) Changes in Pedagogy ♦ Stanford launched a new preclerkship curriculum in 2003. Themes of this curriculum include experiential, small-group learning; early clinical exposure (through the Practice of Medicine course); integration of clinical and basic sciences (through the Human Health and Disease course); and scholarship and discovery. ♦ We are beginning to analyze data from the initial cohorts through our new curriculum, looking at performance on USMLE exams, residency performance, and AAMC GQ measures, among others. ♦ Longitudinal mentorship was introduced in 2009, with the Educators-4-CARE (E4C) program. ♦ As noted earlier, beginning in 2008, each incoming medical student has been matched with an E4C faculty member, who serves as a teacher, mentor, and colleague for the duration of the student's time in the School of Medicine. ♦ E4C faculty play a key role in the development of students' clinical skills, serving as instructors in the Practice of Medicine course, and maintain contact with clerkship students through Doctoring with CARE small-group reflection sessions during the clinical years. Evaluation to measure the impact of this new program is under way (see http://med.stanford.edu/e4c/). Changes in Assessment ♦ The Criterion-Based Evaluation Initiative: Prior to July 2010, all courses and clerkships have been graded on a Pass/Fail basis. ♦ The Pass/Fail system will continue within the preclerkship curriculum. However, beginning in July 2010, students will have the opportunity to be recognized for exceptional performance (“Pass with Distinction”) in each required clerkship. ♦ Evaluation of performance will be criterion-based. All students whose performance meets established criteria will be recognized for exceptional performance, independently of how other students perform. ♦ This approach is in contrast to a curved or norm-based system, where only a certain proportion of students are eligible to earn the top descriptor of performance. Clinical Experiences ♦ The primary training site for the MD program is located in Palo Alto, California: Stanford Hospital and Clinics and Lucile Packard Children's Hospital. ♦ Additional major clerkship training sites include Kaiser Permanente Medical Center in Santa Clara, California; the Veterans Administration Medical Center in Palo Alto, California; and Santa Clara Valley Medical Center in San Jose, California. ♦ Preclerkship and clerkship training also takes place at a number of smaller ambulatory sites, both public and private. ♦ The most significant challenge to clerkship programs is limited capacity. During some clerkship periods, there are an inadequate number of student slots in certain clerkships, necessitating creative ways of scheduling students and alternate experiences to meet educational objectives. ♦ Efforts are currently under way to develop new sites and to develop new clerkship models that would relieve capacity issues while enhancing educational quality. Highlights of the Program/School ♦ Educators-4-CARE: see previous description. ♦ Scholarly Concentrations: The Scholarly Concentrations (SC) program is a required, structured program of study within the MD curriculum that promotes in-depth learning and scholarship. ♦ The SCs provide medical students with faculty-mentored scholarly experiences in areas of individual interest combined with structured coursework. ♦ Of note, students enroll in courses both within the School of Medicine and on the main Stanford University campus to support this scholarship (see http://med.stanford.edu/md/curriculum/scholarly_concentrations/). ♦ Reflections, Research and Advances in Patient Care: This curriculum is designed to provide structured time to “step back” from clerkships to promote reflection on and reinforcement for learning in the clinical environment. Goals include to reflect upon critical experiences in clerkships; to expose students to recent advances in medical discoveries, with emphasis on the perspective of patients; and to continue to develop research and critical thinking skills in areas related to the Scholarly Concentrations.

IlluminationsDevelopment of a manipulative for nephron physiology educationZane C. Giffen and Helena CarvalhoZane C. GiffenVirginia Tech Carilion School of Medicine, Roanoke, Virginia and Helena CarvalhoVirginia Tech Carilion School of Medicine, Roanoke, VirginiaPublished Online:01 Mar 2015https://doi.org/10.1152/advan.00087.2013MoreSectionsPDF (125 KB)Download PDF ToolsExport citationAdd to favoritesGet permissionsTrack citations some physiological concepts, such physiology of filtration and absorption in the different nephron segments, are so detailed that they can be a challenge to be memorized. This article describes an exercise that solidifies learning as students manipulate, using paper models, “transporters” and “electrolytes” in the basolateral and luminal membranes of “nephron cells.” Most important is the opportunity for the students to apply and test their own knowledge related to changes that occur in physiological processes, such as excess of salt or water intake or blood volume alterations, or pathology, such as syndrome of inappropriate antidiuretic hormone secretion, among many other applications.Description of the ManipulativeThis study was applied to first-year medical students at the end of renal physiology lectures at Virginia Tech Carilion Medical School. The protocol was granted exempt status by the Virginia Tech Institutional Review Board (IRB no. 14-039). Students working in self-assigned groups of four or five were given packets containing all necessary materials. Figures 1–3 show examples of one cell, some transporters, and plasma used in this initial study. Complete material is available upon request. Each packet included paper diagrams (8.5 × 11 in.) of the major cell types of the nephron (see Fig. 1 for the early proximal tubule). Small pieces of color-coded cardstock were constructed to represent the major transporters and ion channels present within the various epithelial cells of the nephron (see Fig. 2 for examples of some transporters). Strips of grid paper were used to represent several prominent ions, which were color coded to match the transporters. Ions used in the demonstration included Na+, Cl−, K+, HCO3−, water, amino acids, and glucose, where each box of the grid paper represented 10% of the filtered load of the respective ions (Fig. 3).Fig. 1.An example of the paper cells distributed to students. Blank spaces with arrows serve as placeholders for the placement of transporters, which are shown in Fig. 2.Download figureDownload PowerPointFig. 2.An example of some transporters that were cut out and distributed to students for placement along the basolateral and luminal interfaces of the cells of the nephron. Instructors may easily add or subtract transporters based on their educational goals. NKCC, Na+-K+-2Cl− cotransporter; SGLT, Na+-glucose transporter; AQP, aquaporin; GLUT, glucose transporter; aa, amino acid; ENaC, epithelial Na+ channel; NHE3, Na+/H+ exchanger 3; AE, anion exchanger.Download figureDownload PowerPointFig. 3.Plasma sample. The columns representing ions, water, glucose, and amino acids (AA) were cut into strips and distributed to students, with each strip representing 100% of the respective filtered load of that substance. Students were then able to tear the strips apart to represent reabsorption and secretion as they moved through the cells of the nephron in terms of the percentage of filtered load. The paper strips were presented to students as a “plasma sample,” and the remaining pieces at the end of the activity, after students have moved through all of the cells sequentially, was said to be the “urine” produced.Download figureDownload PowerPointOne important benefit of this teaching methodology is the ability to adapt the manipulative to best fit the instructor's learning objectives. Lecturers may add or subtract pieces from the model to best suit their own classroom needs. In the work described here, we did not cover the transport of Mg2+, Ca2+, urea, organic anions, organic cations, carbohydrates, urate, and ammonia, but they can easily be included using the manipulative.Use of the ManipulativePart 1: basics of the nephron manipulative.Initially, groups were asked to place the cell types of the nephron in sequential order, beginning with the early proximal convoluted tubule and ending with cells of the collecting duct. Groups were then challenged to place the pieces representing the various transporters and ion channels present in the tubular epithelium in their correct locations. Correct placement required students to know not only the appropriate region of the nephron (e.g., the early proximal tubule, late proximal tubule, early distal tubule, and collecting duct) but also the correct side of the epithelial cell (i.e., basolateral or lumen interface). This setup allowed students to assess their knowledge of the nephron and provided an opportunity for peer teaching and discussion among students.Students were then asked to move a “plasma sample” (see Fig. 3) consisting of ions, glucose, amino acids, and water through the glomerulus and then through the cells of the nephron sequentially, demonstrating as they move along how the concentrations of various solutes and molecules changed (in terms of approximate percentage of the filtered load in each nephron segment) until the sample reached the collecting duct to be excreted into the bladder and form the “urine.”Once students had arranged the cells, transporters, and electrolytes to their satisfaction, they were debriefed in a large group format on the correct placement with open discussion among students and faculty members. Questions that checked for comprehension and promoted critical thinking were also posed to the large group during the debriefing session. For instance, when discussing the proximal convoluted tubule, students were asked what percentage of HCO3− is reabsorbed (answer: 80–90%). Students were then asked whether or not there is a HCO3− transporter in the luminal membrane of the proximal tubule (answer: no; HCO3− moves indirectly via Na+/H+ exchanger 3).Part 2: application and integration of knowledge.In the second part of the activity, students were asked to select a scenario that they would present to the rest of the class using the nephron model. Examples of scenarios used are shown in Table 1, but this content can be modified based on the instructor's content needs. For our purpose, as a supplement to the first-year medical education curriculum, we attempted to select scenarios that we felt best highlighted the core physiological principals. Students were encouraged to get creative and were allowed to create additional transporters or hormones out of paper as needed to adequately explain their assigned scenario.Table 1. Examples of scenarios students were asked to demonstrate using the modelA person consumes a bag of salty potato chips, causing an increase in plasma osmolarityA patient with hemorrhagic shockA patient with hypertension treated with diureticsA patient with syndrome of inappropriate antidiuretic hormone secretionAs an example, one group of students was tasked with explaining syndrome of inappropriate antidiuretic hormone secretion to the class and used the model to demonstrate the activation of the V2 receptor by antidiuretic hormone and the subsequent insertion of aquaporins into the apical membrane of principle cells of the collecting duct. Another group discussing hemorrhagic shock decided to draw angiotensin II because they felt it was an essential piece of the scenario that was not included in the initial packet. Each group then presented and described the physiological consequences of their patient scenario, with instructor-led discussion after each presentation.DiscussionStudent feedback immediately after the session was positive and suggested that the activity served as a self-assessment tool that allowed students to gauge their understanding of renal physiology. In a brief postactivity survey, 81% of participants rated the activity as “useful,” “very useful,” or “extremely useful”, and 73% of students found the activity “effective” or “very effective” compared with studying on their own. We intend to further evaluate the model in the upcoming academic year by evaluating student performance on a renal physiology knowledge assessment before and after the manipulative session.One interesting aspect of this model is that the format allowed for the incorporation of all four of the learning styles described in Fleming's revised VARK system (where V is visual, A is auditory, R is reading/writing, and K is kinesthetic) (7). While standard lectures are able to reach visual, aural, and read/write learners to an extent, this hands-on model also incorporates kinesthetic learning styles, which appears to be the most common overall learning preference in studies of medical (10), dental (11), and nursing students (1).The first part of the activity checked for basic knowledge of nephron structure and the second portion, where students applied their knowledge using case scenarios, allowed for an indepth discussion and application to real-world scenarios. This is important because activities that are authentic and applicable to other areas are more highly valued by learners (4). Furthermore, the ability to solve problems and gain an indepth understanding of the underlying concepts will be of more use to students in the long run than any particular piece of factual information (8).A growing body of evidence suggests that students do not retain physiology concepts presented in passive, lecture-based formats (3, 5), suggesting that instructors should implement more active learning into their classrooms. Several active learning techniques have been described for physiology, including neurophysiology (9) and cardiovascular physiology (2). Specific strategies for renal physiology education have also been discussed previously in the literature. Dietz and Stevenson (6) described the successful implementation of active learning in a large medical classroom for renal physiology instruction. They broke students up into small groups and used PowerPoint slides describing medical cases related to renal physiology. TurningPoint clicker questions were then posed to the groups to check for comprehension and encourage class discussion. Through the implementation of such active learning sessions, they were able to reduce renal didactic lecture hours by 25% while enhancing student satisfaction and maintaining student academic performance (6). Here, we describe a different approach to implementing active learning into renal physiology instruction through the use of a manipulative model of the nephron. Our model can be used by itself or to supplement didactic lectures.ConclusionsIn summary, we have developed a nephron manipulative model that is simple and inexpensive to implement. It may be particularly useful in educational settings with limited financial resources that seek to implement small- or large-group active learning sessions. The manipulative also gives instructors a great deal of flexibility in its use. Components can be added or removed to adapt the activity to any given education setting. A variety of different plasma and urine samples may be created to demonstrate how urine laboratory values change with pathological processes. Undergraduate students could focus only on electrolyte movement with or without the transporters. Pharmacy educators could have students use the manipulative to demonstrate the sites of action of various diuretic drugs. Furthermore, the activity can be adapted to different teaching formats. It can be used during a large-group didactic session by the instructor to illustrate key concepts to the entire class or, as it was in our school, as a small-group activity where students were responsible for setting up materials on their own. The manipulative serves as a flexible teaching tool that incorporates multiple learning styles, including kinesthetic learning styles, in an effort to engage students and promote long-term retention of basic and applied nephron physiology concepts.DISCLOSURESNo conflicts of interest, financial or otherwise, are declared by the author(s).AUTHOR CONTRIBUTIONSAuthor contributions: Z.C.G. and H.C. performed experiments; Z.C.G. and H.C. analyzed data; Z.C.G. and H.C. interpreted results of experiments; Z.C.G. and H.C. prepared figures; Z.C.G. drafted manuscript; Z.C.G. and H.C. edited and revised manuscript; H.C. conception and design of research; H.C. approved final version of manuscript.REFERENCES1. Alkhasawneh E. Using VARK to assess changes in learning preferences of nursing students at a public university in Jordan: Implications for teaching. Nurse Educ Today 33: 1546–1549, 2013.Crossref | ISI | Google Scholar2. Carvalho H. A group dynamic activity for learning the cardiac cycle and action potential. Adv Physiol Educ 35: 312–313, 2011.Link | ISI | Google Scholar3. Carvalho H, West CA. Voluntary participation in an active learning exercise leads to a better understanding of physiology. Adv Physiol Educ 35: 53–58, 2011.Link | ISI | Google Scholar4. Cavanagh M. Students' experience of active engagement through cooperative learning activities in lectures. Act Learn High Educ 12: 23–33, 2011.Crossref | Google Scholar5. DiCarlo SE. Too much content, not enough thinking, not enough FUN! Adv Physiol Educ 33: 257–264, 2009.Link | ISI | Google Scholar6. Dietz JR, Stevenson FT. Active learning in a large medical classroom setting for teaching renal physiology. Adv Physiol Educ 35: 456–459, 2011.Link | ISI | Google Scholar7. Fleming ND. I'm different; not dumb. Modes of presentation (VARK) in the tertiary classroom. In: Research and Development in Higher Education, edited by Zelmer A. Brisbane, Australia: Proceedings of the 1995 Annual Conference of the Higher Education and Research Development Society of Australasia, 1995, vol. 18, p. 308–313, 1995.Google Scholar8. Kitchen E, Bell JD, Reeve S, Sudweeks RR, Bradshaw W. Teaching cell biology in the large-enrollment classroom: methods to promote analytical thinking and assessment of their effectiveness. Cell Biol Educ 2: 180–194, 2003.Crossref | Google Scholar9. Krontiris-Litowitz J. Using manipulatives to improve learning in the undergraduate neurophysiology curriculum. Adv Physiol Educ 27: 109–119, 2003.Link | ISI | Google Scholar10. Lujan HL, DiCarlo SE. First-year medical students prefer multiple learning styles. Adv Physiol Educ 30: 13–16, 2006.Link | ISI | Google Scholar11. Shenoy N, Shenoy A, Ratnakar UP. The perceptual preferences in learning among dental students in clinical subjects. J Clin Diagn Res 7: 1683–1685, 2013.Google ScholarAUTHOR NOTESAddress for reprint requests and other correspondence: H. Carvalho, 1 Riverside Circle, Suite 107, Roanoke, VA 24016 (e-mail: [email protected]org or [email protected]edu). Download PDF Previous Back to Top FiguresReferencesRelatedInformation Cited ByEngaging medical students and residents in nephrology education: an updated scoping review5 August 2021 | Journal of Nephrology, Vol. 35, No. 1 More from this issue > Volume 39Issue 1March 2015Pages 39-41 Copyright & PermissionsCopyright © 2015 The American Physiological Societyhttps://doi.org/10.1152/advan.00087.2013PubMed25727468History Received 5 August 2013 Accepted 19 January 2015 Published online 1 March 2015 Published in print 1 March 2015 Metrics

Curriculum Management and Governance Structure Case Western Reserve University (CWRU) School of Medicine (SOM) has two collaborative and innovative educational tracks: University track and College track. ♦ University-based program (University track) was established in 1843 and Cleveland Clinic-based Cleveland Clinic Lerner College of Medicine (College track) was established in 2002. ♦ University track implemented a major curriculum revision in 2006, focusing on development of lifelong learners and incorporating themes of scholarship, clinical mastery, leadership, and civic professionalism. A dedicated four-month research requirement culminating in an MD thesis was incorporated into the four-year curriculum. A hybrid of active, student-centered PBL groups and teacher-centered large and medium group sessions form the backbone of learning venues. ♦ Five-year competency-based College track is designed to train graduates with excellent clinical skills, expertise in research, and a passion for scientific inquiry. Students complete a master's level thesis and graduate with an MD degree with Special Qualification in Biomedical Research. ♦ While course format, assessment approaches, and curricular topics beyond core content of University and College tracks differ, clinical rotations for both tracks were designed collaboratively and implemented jointly. Curriculum Management and Governance Structure ♦ SOM faculty Committee on Medical Education evaluates, reviews, and makes recommendations concerning overall goals and policies of medical education programs for University and College tracks. ♦ Curriculum Monitoring Council (University track) and Curriculum Steering Council (College track) have responsibility for (1) defining and allocating educational objectives, (2) approving teaching methods and instructional formats, (3) monitoring coordination and integration of curricular content, (4) selecting assessment methods to document student performance, (5) monitoring quality of teaching, (6) overseeing curricular and program outcomes. ♦ Basic science leadership groups for each track facilitate sharing of best educational practices among course leaders, design and implement programs to ensure basic science mastery, and facilitate smooth implementation of methods of student assessment. ♦ Joint Clinical Oversight Group (JCOG) monitors and evaluates clinical experiences at affiliated teaching hospitals of CWRU SOM. JCOG oversees curriculum design, program evaluation, educational quality, student assessment, and compliance with LCME and institutional requirements for the clinical curriculum. ♦ The Dean is chief academic officer responsible for both education tracks. ♦ The Dean delegates day-to-day responsibility for both tracks to the Vice Dean for Education and Academic Affairs. The Executive Dean for the College track reports to the Vice Dean for Education and Academic Affairs. The Executive Dean for the College track is also accountable to the Chief of Staff of the Cleveland Clinic with regard to Cleveland Clinic resources and support for the College track. Curriculum Support Offices ♦ Offices of Curricular Affairs for each track include an associate dean for curricular affairs, MD and PhD educational leaders, and administrative staff who provide support for their respective educational programs. These offices support curriculum development and implementation, ongoing quality improvement, student assessment, and program evaluation. They work collaboratively with respective offices of information technology to develop, improve, and maintain extensive electronic curricula, student assessment resources, and program evaluation methodologies. ♦ Each track has a director of undergraduate clinical education, support staff, and physician and nonphysician educators to support components of clinical curriculum for each track and collaborate on the joint clinical program. ♦ Both tracks have robust faculty development programs to support teaching and implemented initiatives to encourage educational scholarship. Financial Management of Educational Programs ♦ When the Dean committed to revision of the University track's curriculum in 2004, a new curriculum budget was established to support University track curriculum development, implementation, ongoing program maintenance, and improvement. ♦ CWRU School of Medicine has affiliation agreements with its major teaching hospitals. As a part of affiliation agreements with three teaching hospitals, faculty are expected to contribute 100 hours annually to medical school teaching activities. University track established a faculty-teaching database that provides ongoing reports about faculty teaching effort to department chairs. ♦ All College track faculty are salaried employees of a central Cleveland Clinic budget, allowing Department Chairs to allocate release time for teaching and service activities. Valuing Teaching ♦ Qualifications for faculty appointments include “a high level of teaching effectiveness,” with documentation of quality and quantity of teaching activities within teaching portfolios. ♦ Nontenure track faculty appointments are based on an area of excellence: teaching, clinical service, or research. ♦ In addition to schoolwide and departmental teaching awards, faculty are invited annually to submit applications for Scholarship in Teaching awards. Applications are peer-reviewed, and each year 20–30 faculty are recognized by the Dean at the Annual Education Retreat. ♦ Cleveland Clinic faculty are recognized for teaching as part of annual performance reviews, which are used to determine promotion and salary decisions. College track maintains a database of faculty leadership and teaching activities for all components of the curriculum; summary information is provided to faculty members and chairs as part of the reviews. Curriculum Renewal/Development Process University Track Curriculum Development ♦ Major curriculum transformation, Western Reserve2 (WR2), launched July 2006. ♦ Key Objectives for Curriculum Development Process Medical education will be experiential and emphasize skills for scholarship, critical thinking, and lifelong learning. Educational methods will stimulate an active interchange of ideas among students and faculty. Students will be immersed in a graduate school educational environment with flexibility and high expectations for independent study and self-directed learning. Learning will be fostered by weaving scientific foundations of medicine and health with clinical experiences throughout the curriculum. These scientific foundations include basic science, clinical science, population-based science, and social and behavioral sciences. Every student will have an in-depth mentored experience in research and scholarship. Recognizing obligations of physicians to society, central themes of public health, civic professionalism, and leadership will be longitudinally woven throughout the curriculum. Systems issues of patient safety, quality medical care, and health care delivery will be emphasized and integrated throughout the curriculum. Students will acquire a core set of competencies in knowledge, mastery of clinical skills, and attitudes that are prerequisite to graduate medical education. Learning Outcomes/Competencies ♦ WR2 Curriculum is based on nine core competencies with well-defined achievement levels for each that serve as educational objectives (medical knowledge, patient care, communication skills, professionalism, lifelong learning–personal development, research and scholarship, civic professionalism–health advocacy–leadership, problem-based learning and improvement, systems-based practice). Components of the Curriculum Development Process ♦ Preclerkship basic science portion of WR2 curriculum is 20 months in length with six systems-based course blocks that integrate normal and abnormal content throughout (Chart 1).CHART 1: University Track Basic Science Curriculum♦ Weekly in-class basic science teaching is limited to 16 hours a week, paired with high expectations for self-directed learning outside the classroom. ♦ A wide range of dual-degree opportunities are available for students to pursue. ♦ One week of each block is dedicated to experiences in the clinical setting. During Clinical Immersion Weeks, students have opportunities to see how basic science concepts learned in the classroom translate to and impact on patient care. ♦ First block of the curriculum, five weeks in length, is “Becoming a Doctor.” It introduces students to medical school education at the macrolevel with a focus on social and behavioral context of health and disease. ♦ Themes from the first block and additional content in Health Policy, Bioethics, Doctor–Patient relationship, and sociobehavioral medicine are continued in weekly 2-hour seminars. ♦ Case Inquiry Groups (IQ groups), based on McMaster's revised PBL format, serve as a core teaching method for six of the formal teaching hours (three 2-hour sessions per week). ♦ Anatomy, histopathology, and radiology are integrated into a longitudinal “Structure” block. ♦ Learning from multiple sources is emphasized (including a rich array of web-based resources); previous extensive written syllabus was eliminated. ♦ Weekly Foundations of Clinical Medicine Seminars (Doctoring Course) integrates with IQ cases when appropriate. ♦ Sixteen-week mentored research experience with MD thesis is required for all students. Components of the Assessment Process ♦ Goal of deep learning, synthesis, and information transfer expected in WR2 requires that assessment strategies align with curriculum objectives. ♦ CWRU SOM's longstanding pass-fail, criterion-referenced assessment system in the preclerkship curriculum was maintained. ♦ Weekly formative assessments include 20–30 multiple choice questions and 2 synthesis essay questions primarily based on content of the week; these are open book, and group work is encouraged. ♦ End of block basic science summative assessment is a 4- to 5-hour synthesis essay examination; each essay is vignette-based and incorporates multiple concepts and transfer of knowledge to new contexts. ♦ There is an end of block summative anatomy and histopathology examination with practical, short answer, and multiple choice portions. ♦ At the end of each block, students take a formative multiple choice test developed through the NBME customized assessment services. Each test has questions specific to current block of study as well as questions assessing material from previous blocks. This enables students to monitor their progress in studying for USMLE Step 1. ♦ At midpoint of each block, students engage in a personal quality improvement exercise by defining an area for improvement and developing a Professional Learning Plan of action. ♦ Students complete an end of year reflective portfolio to assess progress in nine core competencies. ♦ IQ group performance within areas of (1) contributions to group content and process, (2) skills of critical appraisal, and (3) professional behaviors are evaluated by IQ group faculty facilitators; students engage in peer assessment as well. ♦ Performance in preclerkship clinical curriculum is integrated into the overall assessment process and incorporates formative OSCEs, preceptor feedback, and student reflections. New Topics in the Curriculum Since 2000 ♦ Quality improvement and patient safety, longitudinal theme across four years ♦ Leadership and teamwork, evolving as longitudinal theme across four years ♦ Population health ♦ Increased emphasis on longitudinal development of communication skills, both preclerkship and clerkship components with opportunities for peer teaching in fourth year ♦ Health policy and health care economics Changes in Pedagogy ♦ Student-centered problem-based learning groups (Case Inquiry Groups) ♦ No formal syllabus; rich electronic curriculum guides students to multiple sources for study ♦ Increased emphasis on self-directed learning ♦ Decrease in formal classroom time ♦ Selective videotaping of educational activities; 16 hours of core classroom time not videotaped ♦ Weekly formative assessment and integrative summative assessment ♦ Summative essay examinations focus on synthesis and integration of concepts ♦ Portfolios used to assess nine core competencies ♦ Increased emphasis on clinical context of basic science concepts through IQ cases and clinical immersion activities ♦ Developmental introduction of clinical reasoning skills and case presentations through IQ groups ♦ Integration and extension of basic science curriculum into core clinical clerkships Program Evaluation ♦ Students complete online confidential surveys assessing their perceptions of course faculty, content and instructional methods, and learning resources. ♦ Curriculum committees, individual faculty instructors and course leaders, education leaders, and department chairs receive reports following each course or rotation. ♦ Curriculum effectiveness is assessed by tracking USMLE scores, residency program directors' perceptions, and graduation questionnaire responses. Scores on the Cognitive Behavior Survey, Attitudes toward Social Issues in Medicine, Learning Climate Inventory, Research and Scholarship Checklist, and Case Lifelong Learning Scale are also tracked. College Track Curriculum Development Components of Curriculum Development Process ♦ Affiliation agreement between Cleveland Clinic and CWRU in 2002 ensuring compliance with LCME strategies and appropriate oversight by CWRU. ♦ Mission to train physician investigators who will advance biomedical research and medical practice. ♦ Series of faculty retreats Identified outcomes for College track graduates: independent thinkers, self-directed learners, team players, strong clinical skills, broad-based research skills, scientific inquisitiveness. Developed curricular principles that guided curriculum development: provide a graduate school environment where students are responsible for their learning and seminars focus on application of knowledge; use active learning methods; research is major curriculum thread culminating in master's level thesis; students guided in personal and professional development of physicians and researchers by faculty dedicated to these activities; sufficient time and flexibility in curriculum to accommodate independent study and investigation; basic science, research, and clinical experience integrated into all years of the curriculum. ♦ All students participate in 9- to 10-week summer research experience in basic/translational research (year one) and clinical research (year two) in addition to two-year organ-based basic-science curriculum (Chart 2).CHART 2: College Track Basic Science Curriculum♦ Each week of the curriculum has a theme around which three 2-hour PBL sessions, 8 hours of seminars, and one hour of Advanced Research in Medicine seminars are organized. ♦ Foundations of Clinical Medicine seminars are held weekly. ♦ Thirteen Thread Leaders (representing sciences basic to medicine such as anatomy, physiology, ethics, epidemiology, and biostatistics) charged with responsibility to develop learning objectives for their discipline and work with organ-system course directors to determine best placement of these objectives in the curriculum. Curriculum Steering Council monitors implementation. ♦ Each student is assigned to a family medicine or internal medicine longitudinal preceptor during years one to two; students develop clinical skills with preceptors in every other week half-day sessions in year one and weekly sessions in year two; additional experiences include pediatrics, geriatrics, and acute care. ♦ Formal curriculum hours limited to 21 hours weekly; curriculum changes are time neutral to maintain flexibility for students. ♦ Opportunities available to earn master's degrees (Public Health, Engineering, Biomedical Investigation in Clinical Research, Nutrition, Pathology, or Biochemistry). ♦ Cleveland Clinic provides full tuition scholarships to all College track medical students to avoid significant financial debt at graduation and thereby facilitate entry into research careers. Learning Outcomes/Competencies ♦ The curriculum is based on nine competencies; seven reflecting ACGME competencies (medical knowledge, clinical skills, clinical reasoning, communication, professionalism, health care systems, reflective practice) as well as research and personal development. ♦ Each competency has three to five specific standards for students to achieve by the end of years one, two, and five. Components of the Assessment Process ♦ Goal of the College track assessment process is to help students become reflective practitioners of medicine complemented by a critical approach to self-assessment and self-improvement. ♦ Faculty developed assessment principles that require frequent, formative assessments to enhance student learning and engage students in ongoing cycles of self-assessment, supported by mentoring from physician advisors. ♦ Assessments align with the College track's nine competencies and developmentally appropriate standards; there are no grades or class rankings. ♦ Assessments are collected from multiple sources (faculty, peers, self) and multiple methods (OSCEs, faculty observations, MCQs) and contexts to provide students with frequent narrative formative feedback across the curriculum to identify strengths and areas needing improvement and document students' achievement of competency standards. ♦ In basic science courses, weekly CAPPS (concept appraisal essays) require students to integrate and apply knowledge to solve problems related to course material. ♦ All assessments collected in an ePortfolio for students and their advisors to reflect on and monitor progress longitudinally. ♦ Students use their assessment data to construct both formative and summative portfolios that document achievement of competency standards. ♦ Students' formative portfolios are reviewed with their advisors to develop learning plans; summative portfolios are reviewed by a Medical Student Promotion and Review Committee for promotion decisions. New Topics in the Curriculum Since 2006 ♦ Clinical reasoning in year two. ♦ Integrated program in medical humanities. ♦ Bioinformatics taught as a component of the Genetics Thread progressively over first two years. Changes in Pedagogy ♦ Course directors have increased use of small group sessions (eight students per group) whenever possible to improve teacher–student and student–student interactions and increase student learning. ♦ Emphasis on faculty development to assist faculty in developing skills in small group, interactive teaching, and providing useful formative feedback. Program Evaluation ♦ College track uses a systematic approach based on principles (collect only essential information, and so on) to determine fulfillment of institutional goals, identify curricular strengths and areas requiring improvement, and contribute to educational research. ♦ Student feedback is collected for all courses and track-specific innovations (portfolio-based assessment, research thesis, and so on) using multiple methods (debriefing meetings, web-based questionnaires, performance assessments, focus groups). ♦ Office of Curricular Affairs for College track summarizes evaluation evidence for each course into formal reports for course directors and related committees to identify curricular strengths and limitations. ♦ Course directors reflect on this information and prepare written reports for presentation to respective curriculum committees and approval by College track's curricular governance committee. ♦ Office of Curricular Affairs uses external, track-specific data (AAMC Matriculation and Graduation Questionnaires, USMLE reports) for bench-marking purposes. ♦ Since College track's inception, assessment and program evaluation data maintained in IRB-approved data registry to ensure ethical practices for program evaluation and educational research. Clinical Experiences ♦ Clinical instruction and rotations for both tracks designed collaboratively and shared from third year onward. ♦ Four affiliated teaching hospitals: University Hospitals/Case Medical Center, Cleveland Clinic, MetroHealth Medical Center, Veterans Affairs Medical Center. ♦ Clinical rotations begin March of second year. ♦ Required clinical rotations: 40 weeks of basic core rotations, 8 weeks of advanced core rotations, and two subinternships Three basic cores, each completed at one site Basic Core 1 (medicine and surgery, 16 weeks) Basic Core 2 (pediatrics, OB–Gyn, family medicine, 16 weeks) Basic Core 3 (neuroscience and psychiatry, 8 weeks) Two advanced cores Aging and Society (4 weeks) Undifferentiated and Emergent Care (4 weeks) ♦ Robust electronic Clinical Assessment System (CAS) combines patient logs with real time formative feedback and summative assessment in competency-based format. ♦ Track-specific curriculum one afternoon a week at students' home base University track: IQ+ program to integrate reflection, basic science content, and advanced clinical skills into clerkships College track: programs in advanced research skills and medical ethics and humanities ♦ Challenges Achieving uniformity in student assessment across broad base of faculty Students' desire for more formative assessments from faculty; challenging to encourage busy faculty to provide more frequent written narratives Supporting clinicians' time for teaching Moving faculty and students to consider new models for clinical education Highlights of University Track ♦ High expectations for active, student-centered learning ♦ Case Inquiry Groups: new PBL variant with shorter, more focused cases ♦ Clinical immersion weeks embedded within basic science blocks ♦ Integrative essays to assess basic science knowledge ♦ Sixteen-week research and scholarship requirement with MD thesis ♦ Integration of SNAPPS case presentations across four-year curriculum to enhance expression and strengthening of clinical reasoning ♦ Portfolio assessment of competencies ♦ Integration of basic science into core clerkships through weekly IQ+ program Highlights of College Track ♦ Small class size promotes collaborative learning environments, interactive teaching methods, collegial relationships with faculty ♦ Five-year integrated research curriculum and required master's level thesis ♦ Reliance on formative assessments to document student achievement of competencies; no grades, no class ranking ♦ Portfolio approach for competency-based assessment system ♦ Institutional commitment to faculty development for teaching and assessment roles and full tuition scholarships for all College track students ♦ Comprehensive program evaluation activities Highlights of Shared Clinical Curriculum ♦ Clinical Assessment System featuring continuous formative assessment ♦ Clerkship groupings in 8- to 16-week integrated blocks ♦ Advanced cores introduce new, innovative curricular content ♦ Dedicated curriculum time during clerkships for program- specific educational goals

The teaching and learning activities of any undergraduate curriculum will have a specific set of learning outcomes that should be successfully achieved by the students. The balance between the workload of a student and the available time to achieve the learning outcomes plays a major role in achieving these learning outcomes, as well as a good student satisfaction score and excellent final grades for that particular module (Whillier & Lystad, 2013). In a traditional educational experience, a teacher stands in front of the classroom, delivers a lecture to a group of students, who sit in rows, quietly listening to the lecture and taking notes. At the end of the lecture, students are given homework or an assignment to be completed outside of the classroom environment. This characterises the principle of “sage-on-the stage”, and is synonymous with the present day term of teacher-centered learning. This is also referred to as the transmittal model (King, 1993), which assumes that the students are passive note-takers, receivers of the content or accumulators of factoids (Morrison, 2014). Usually, the teacher does not have time to interact with the students individually during the class (Hamdan, McKnight, McKnight & Arfstorm, 2013), thus neglecting those students who do not understand the lecture. The traditional didactic way of teaching is primarily unidirectional and consists of limited interactions between the source of knowledge (teacher) and the passive recipients (students). One of the main challenges faced by lecturers is the overload of academic content that needs to be taught in a relatively short period of time. Equally, the main challenge faced by the students is loss of interest or motivation to learn within the stipulated period of time (Prober & Khan, 2013). The traditional way of teaching, therefore, discourages the students from active learning and critical thinking. There is also increasing pressure from accreditation institutions, which demand “an ability to communicate effectively”, “an ability to identify, formulate and solve problems”, and “an ability to function on multidisciplinary teams” (Bishop & Verleger, 2013). As such, there is a need to transform the current pedagogical strategies, in order to enhance active learning in a more effective way (Al Faris et al., 2013). Synthesis of research on the effectiveness of lectures shows that lectures are not very effective for teaching and developing values or personal development, and may only be effective for the sole goal of transmitting information (Bligh, 2000). Taking these points together, it is important to explore methods that have the potential to maximise the use of classroom time and transform the classroom into a platform for teacher-student interactions and critical thinking (Rui et al., 2017). Numerous factors have cumulatively led to several challenges for traditional teaching in health professional education (HPE), including the availability of digital technologies, digitally-empowered learners, the prolific expansion of courses, the amount of factual knowledge that has accumulated in the courses, prolific growth of health knowledge, advancement in healthcare disciplines, and investment into the scholarship of teaching and learning. To this end, newer delivery systems encompassing active learning in HPE have been developed. Studies have reported that active participation is an effective method to improve learning and understanding (Freeman et al., 2014; McCoy et al., 2015). Thus, to enhance interaction during their learning, there are educational strategies, which promote active learning in traditional lectures by engaging students in doing things and encouraging them to think about what they are doing. A classic example of active learning is a think–pair–share discussion, in which a student thinks individually for a moment about a question posed on the lecture, then pairs up with a classmate to discuss their ideas, and subsequently shares their answer with the entire class (King, 1993). There are various modifications which can be incorporated into traditional lectures that enable active learning in the classroom, for instance; (a) the feedback lecture, which consists of two mini lectures separated by a small-group study session built around a study guide, and (b) the guided lecture, in which students listen to a 20- to 30-min presentation without taking notes, followed by their writing for 5 min on what they remember, and spending the remainder of the class duration in small groups for clarification and elaboration on the study material (Ellis, 2010; Johnson, 2013). Moreover, there are other active learning pedagogies, which include visual-based instruction (Johnson et al., 2016), small group problem based learning, cooperative learning, debates, drama, role playing and simulation and peer teaching. One innovative approach in education delivery system is the “flipped classroom,” an educational technique that consists of two parts, interactive group learning activities inside the classroom and direct personal computer-based individual instruction outside the classroom (Bishop & Verleger, 2013). As such, work typically done as homework in the didactic model (e.g., problem solving, essay writing) is better undertaken in class with the guidance of the teacher. Listening to a lecture or watching videos is undertaken at home. Hence, the term flipped or inverted classroom is used (Herreid & Schiller, 2013). The essence of a flipped classroom is that the activities carried out during traditional class time and self-study time are reversed or “flipped” (Veeramani, Madhugiri & Chand, 2015). Approaches to undergraduate teaching have improved over the years as the scholarship of learning and teaching has provided evidence of what works to improve the outcomes. However, educational delivery approaches have shown little change in many disciplines and have remained the same for the majority of the sectors (Van Vliet, Winnips & Brouwer, 2015). The flipped class is flexible itself and can be tailored (Tetreault, 2013). Historically, the concept of flipped classroom started in early 1990s. General Sylvanus Thayer created a system at West Point in USA, where a set of learning materials was given to engineering students so that they obtained core content prior to attending class. The classroom space was then used for critical thinking and group problem solving (Musallam, 2011). Many credited the rejuvenation of this idea with the development of, and increased access to, educational technologies (Moffett, 2015). For instance, the School of Business at the University of Miami proposed an ‘inverted classroom,’ which had events that traditionally took place inside the classroom now taking place outside the classroom and vice versa (Lage, Platt & Treglia, 2000). In 2000, a conference paper entitled ‘The Classroom Flip’ was presented by J Wesley Baker and the phrase ‘flipping the classroom’ was coined. Baker described how flipping the classroom could allow the trainer to become the ‘guide on the side’ rather than the ‘sage on the stage’ (Baker, 2000). In a sense, this reversal also flips the Bloom's revised taxonomy because the lower level of cognitive work/knowledge acquisition is done by the students, while educators work interactively with the students to develop the higher forms of cognition (Figure 1). To date, this approach has attracted a large amount of attention in the HPE and a subsequent surge of literature. A comparison between the traditional learning and the flipped classroom in the Bloom's taxonomy [Color figure can be viewed at wileyonlinelibrary.com] Fundamentally, a flipped classroom encompasses two established elements of education, the recorded lecture (off campus learning) and active learning (on campus learning). Lectures are given as homework, as an aid to learning. Homework is important because it is a time where students can share their learning progress with their family, reflect on their learning, and review the material as well as the educator's feedback (Fulton, 2012). The key characteristics of a flipped classroom compared to a traditional classroom and other existing teaching methods are summarised in Table 1. It has been highlighted that the flipped classroom fits into the broader context of blended learning (Tetreault, 2013). Blended learning as defined by Staker is ‘a formal education program in which a student learns at least in part through online delivery of content and instruction with some element of student control over time, place, path, and/or pace and at least in part at a supervised brick-and-mortar location away from home’(Staker & Horn, 2012, p.3). The flipped classroom consists of a formal education program, and online learning as a mechanism of informal learning through educational video quizzes/games. The flipped classroom approach is connected between what the students learn online (e.g., video lecture) and what they learn face-to-face (e.g., in-class active case study), and vice versa, which is a common feature of blended learning (Tetreault, 2013). In principle, the flipped classroom assigns relatively low-level cognitive learning such as memorising and understanding, outside of the classroom and teaching in class is accomplished mostly through teacher-student interactions and cooperation between peers, thereby stimulating the students’ intellectual potential (Rui et al., 2017). The option to view video lectures (as an example) outside of classroom has beneficial effects for the learners as they can replay the videos as many times as needed to better understand the key concepts at their own pace. Furthermore, this allows each student to be able to comprehend the topics being covered to his/her satisfaction, whereas this might not be possible in the context of conventional teacher-centred teaching. This is an important pedagogical consideration for international students for whom English is their second language (Moraros, Islam, Yu, Banow & Schindelka, 2015). From the teacher's perspective, a flipped classroom setting makes it easier to engage students and empower them as active participants of their own learning. There are several theoretical constructs that are applicable for a flipped classroom. Two of these include: the technology acceptance model (TAM) (Davis, 1989) and the unified theory of acceptance and use of technology (UTAUT) (Venkatesh, Morris, Davis & Davis, 2003). These theoretical constructs provide a framework for the analysis and identification of relevant outcomes. We will outline how these two theories of flipped classroom learning can improve the learning outcomes such as student satisfaction and improved scores. TAM includes two theoretical constructs: (a) perceived usefulness and (b) perceived ease of use. These constructs are defined as "the degree to which a person believes that using a particular system would enhance his or her job performance" and "the degree to which a person believes that using a particular system would be free of effort", respectively (Davis, 1989, p320). The first theoretical construct relies on students’ prior knowledge, gained from the pre-class video lecture (for example), in enhancing their understanding (and overall learning performance) in the active in-class activities such as problem solving. The second theoretical construct is based on students' perceptions that if a flipped class room is more user friendly than the traditional teaching mode, then they would be more likely to accept it. The goal of the UTAUT model is to explain the intentions of a user to use a given information system and the subsequent behaviour of the user. The model is based on four primary constructs: 1) performance expectancy, 2) effort expectancy, 3) social influence, and 4) facilitating conditions (Venkatesh et al., 2003, p447). The first three constructs reflect the motivation of the users (i.e., students). The fourth construct reflects the characteristics of a flipped classroom setup when students engage with the pre-class materials that are uploaded on an e-learning portal. These material could be a video, an interactive presentation, a questionnaire or sometimes a recorded audio. With regard to these theoretical constructs, if students perceive that a flipped class room is user friendly and the academic environment facilitates their learning, then it will promote students' engagement, interactions and cooperation in learning, which will further improve their performance. There are potential advantages of a flipped classroom, including increased opportunities to provide individualised education to learners (Johnson, 2013; Kachka, 2012), increased student engagement with course material (Gross, Pietri, Anderson, Moyano-Camihort & Graham, 2015), and increased educator-student interaction, compared to a ‘performing’ lecture. The Kirkpatrick model of educational outcomes (Barry Issenberg, McGaghie, Petrusa, Lee Gordon & Scalese, 2005; Kirkpatrick & Kirkpatrick, 1994) comprises ‘learners’ reaction’ (to the educational experience); learning (modification of attitudes/perceptions and the acquisition of knowledge and skills); behaviour (self-reported changes in practice and observed changes in practice, including new leadership positions); and results (which refers to change at the level of the organisation) (Figure 2). For instance, regarding the 'results' outcome, the flipped classroom allows the teacher to gain advanced, real-time insight into how students learn and quickly identify and better address curriculum content that the students find most challenging. This insight can be used to better inform decisions with regard to effective curriculum organisation, structure and the delivery of future classes. Four levels of learning in Kirkpatrick's model [Color figure can be viewed at wileyonlinelibrary.com] The success of a flipped classroom approach relies on a number of assumptions. Stimulation of students’ interest in learning and guided self-study (Moraros et al., 2015), primarily depends on the opportunities to actively engage students in self-directed learning and encourage progressive improvement (Bergmann, Overmyer & Wilie, 2012; Moraros et al., 2015) in assessment performances. Thus, a flipped class will not support effective learning if students fail to engage with the assigned pre-class or in-class activities (Kachka, 2012), for reasons which might include poorly designed educational materials (e.g., long, poor audio quality) or students feeling ‘lost’ (Moffett, 2015). As such, a number of contextual and structural factors that can influence flipped classroom learning include resources (inputs to the program), activities (aspects of implementation), outputs (observable products of the completed activities) and outcomes (effects or impacts within various time frames) as depicted in the conceptual framework (Figure 3). Logic model of flipped class learning [Color figure can be viewed at wileyonlinelibrary.com] There are individual studies, which have evaluated flipped classroom in medical education, allied health education and health science education, using a pre-and post-test design or comparative designs to explore how learning outcomes are improved. Some studies showed positive outcomes with flipped classroom (Galway, Corbett, Takaro, Tairyan & Frank, 2014; Van Vliet et al., 2015), while others showed the opposite (Whillier & Lystad, 2015). For instance, a study on integrated flipped lectures with online teaching techniques assessed learning experiences and participation through active learning. The findings suggested that the students in the integrated flipped-online lectures had achieved an increase in active learning components compared to the group that were put in a didactic model (Galway et al., 2014). It is important to understand the factors that could have contributed to this difference. As an example, for balance of the safe learning environment (to be free from discomfort and fear) between the two groups of students, a comparability of the personality traits between the students in each group needs to be considered. On the other hand, another individual study, which assessed the effectiveness of flipped classroom in ophthalmology clerkship reported that the students in flipped classroom had more burden and pressure in preparing for the pre-class compared with the students in lecturer-based classroom group. Thus far, these published individual studies varied in design, sample size and outcome measures. It is unclear, if these findings would be generalised to other HPE. A non-Campbell systematic review of the flipped classroom reported how the flipped classroom has been applied in nursing education and the achieved outcomes associated with such teaching (Betihavas, Bridgman, Kornhaber & Cross, 2016). Due to the focus on a particular educational context (i.e., nursing or ophthalmology), the generalisability of their findings to other courses in undergraduate HPE is uncertain. Another non-Campbell collaborative systematic review, consisting of 82 studies reported on the effectiveness of flipped classroom in medical education where a pooled estimate of a subset of six experimental studies showed generally positive perceptions of the students to the flipped classroom. However, there were no significant changes in knowledge and skills (Cohen's d = −0.27 to 1.21, median: 0.08; Chen, Lui, & Martinelli, 2017). These systematic reviews, focused on a particular area (either nursing education or medical education) had a limited number of included studies, considerable variation in study designs, a lack of methodological quality assessment of the included studies, and the quality of evidence reported by these systematic reviews is poor. A systematic review which combines the results of interventions, using flipped classroom compared with alternative learning or traditional learning, will help us to make recommendations for the development and implementation of successful flipped classroom amongst health professionals. The current review also aims to serve as a reference for decision makers to support evidence-based approaches to flipped classroom in HPE. The primary objective of this systematic review is to assess the effectiveness of flipped classroom intervention for undergraduate health professional students on academic performance and course satisfaction. The influence of context in the design, delivery and outcomes of the flipped classroom interventions in undergraduate health professional education; The barriers and facilitators of flipped classroom learning effectiveness for undergraduate health professional students. Specifically, this review is designed to answer the following research questions: What are the effects of flipped classroom learning on undergraduate health professional students' academic performance? What are the effects of flipped classroom learning on undergraduate health professional students' course satisfaction? Do any moderator variables affect the effectiveness of flipped classroom learning on academic performance outcomes? Moderators will include (if data are available), study design, student related factors such as the amount of out-of-class preparation time, classroom availability and limited high speed internet access for rural and remote students, quality of interactive tools, and faculty related factors such as faculty members' preference to a more didactic approach. Randomised designs, which include individual-level randomised trials, cluster-level randomised trials and natural experiments, where assignment to treatment or control conditions is functionally random. Non-randomised designs, which include at least one treatment group and at least one comparison group, matching designs, two-group pre-post designs, regression discontinuity designs. We do not include qualitative research. We included all undergraduate health professional students, regardless of the type of healthcare streams (e.g., medicine, dentistry, nursing, pharmacy), duration of the learning activity (e.g., one or two semesters) or the country where the study is conducted. Any educational intervention that includes the flipped classroom as a teaching and learning activity in undergraduate programmes, regardless of the type of healthcare streams (e.g., medicine, dentistry, nursing, pharmacy) will be considered. To be included, a study must explicitly indicate that the teaching/learning activities for undergraduate students included in the flipped classroom, reversed classroom or flipping class, aiming to improve student learning and/or student satisfaction. Standard lectures and subsequent tutorial formats will not be considered as flipped classroom. Studies on flipped classroom methods among undergraduate or postgraduate students who are not from the healthcare streams (e.g., engineering, economics, computer science) will be excluded. We explored the impact of flipped classroom learning in undergraduate health professional students on academic related outcomes. The primary outcome is academic performance measured by examination scores, final grades or other formal assessment methods at immediate post-test. The secondary outcome is student satisfaction measured at immediate post-test using a self report scale, which may include the training institution's own format of assessing student satisfaction. 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