Flipped Learning: “Turning learning on its head”

Here’s a scenario of an innovative educational method that is sweeping through the halls of academia:  Imagine…students are hard at work at home accessing captured lectures, PowerPoint slides, audio or video casts, reference books, or other resources to learn about foundational factual material.  They then go to class to spend the teaching/learning time on applied cases, projects, or problems where they can question the teacher, and work with their classmates on solutions and discoveries.  Sound familiar?  This is an example of “Flipped Learning”.  I’d like to show you that we at Queen’s Meds are way ahead of the curve—we’re practicing “flipped learning” in “flipped classrooms already!”

A brief history of the Flip:

In 2000, J.W. Baker presented on a “Classroom Flip” where he used technology to allow students to read and learn at home, and became the “guide on the side” for them in class.

Formally defined in the literature by Lage, Platt and Treglia (2000) as the “Inverted Classroom”, the authors, from the Economics Department at Miami University, outlined a multimedia strategy for teaching that “appeals to a broad range of learning styles, without violating the constraints faced by instructors at most institutions.” (p. 31). By inverting the teaching and learning that took place inside and outside their economics classroom, the teachers gained more time to address diverse learning styles and challenges.  They allowed groups and individual students to do their “homework” in the classroom, and reserved traditional lectures for outside the classroom.

In 2007, two high school chemistry teachers, Bergmann and Sams, recorded their PowerPoint lecture presentations using then newly developed screen capture software. Bergmann and Sams had built the videos for absent students to catch up, but found that students who had been present accessed the material to study and review.  This left them time to spend in a classroom, on inquiry, and “deeper learning.”  According to Bergmann, the Flipped Classroom “took off like a rocket!”  (Bergmann, 2012.)

In March 2011, at Ted Talk, Salman Khan, spoke about flipping the homework/lecture equation.  A hedge fund manager with multiple degrees in math and science from MIT Khan created the  Khan Academy (www.khanacademy.org/), from his original math tutorials for his niece, to a very successful and free source of over 2,600 online tutorials covering everything from math, chemistry and even medicine. (Kahn, 2011). “Khan asserts that teachers in a traditional classroom spend five percent of their time actually working with students, while spending the other 95 percent lecturing, creating lectures or grading. Using Khan’s free online math tutorials, teachers flipped this equation, using technology to “humanize the classroom.”   (Huston and Lin, 2012).

The growth in acceptance of this method is evidenced by, among many things, the best selling Bergman and Sams (2012) ISTE publication “Flip Your Classroom: Reach Every Student in Every Class Every Day.”

So, that’s what the “flip” is all about.  What are we doing here in Queen’s Meds and what are some of the challenges we have to overcome in our use of “flipping”?

If you’re teaching in Undergraduate Medical Education (UGME), chances are you’ve come across our “SGL’s” or “Small Group Learning” sessions.  With Dr. Lindsay Davidson’s example to guide us, we in UGME have adapted Team Based Learning (TBL) for these sessions.  Here, we provide students with what had previously been the purview of the lecture: foundational facts through readings or other resources, from textbook chapters with reading guides, to online modules, complete with interactive quizzes, videos, etc.  Students are provided with some “homework” time in our Directed Independent Learning sessions and are expected to come to class prepared to engage in inquiry through group work, with cases, or problems where they can apply their learning.  The faculty member, often with a colleague, (other faculty, residents or fellows), facilitates the session, but notes that if he/she is talking more than 25% of the time, he/she is straying into the other side of the flip and not focusing on the student learning.

Why did we do this?  For the same reasons that the flipped classroom is reaching so many teachers and students.

Here’s what Jon Bergmann has to say about this type of learning:

  • Flipped Learning transfers the ownership of the learning to the students.
  • Flipped Learning personalizes learning for all students
  • Flipped Learning gives teachers time to explore deeper learning opportunities and pedagogies with their students (PBL, CBL, UDL, Mastery, Inquiry, etc)
  • Flipped Learning makes learning (not teaching) the center of the classroom.
  • Flipped Learning maximizes the face to face time in the classroom. (Bermann, 2012)

Now, what are some of the challenges? And how can we address them?

  1.  It’s important that the students have prepared before coming to class.  We do this by a.  appealing to students’ sense of responsibility and professionalism, b.  appealing to students’ common educational sense (they have to prepare if they are going to work on the applications) c.  tying the preparation to assessment and grades into the preparation, d.  using Readiness Assessment Process (lovingly known as RATs) which allow for enhanced group learning of concepts.
  2. Flipped Classrooms came about through innovations in technology that allowed for Lecture Capture, Narrated PowerPoint, and other technological tools.  The key is not to get carried away with the technology but focus on the value of what is being offered to students:  on guiding them through the learning and then inextricably weaving it with what is going to happen in class.  One indispensible factor is quality:  the captured lecture, online module, or even textbook chapter must have been carefully selected and/or crafted the way any good teaching tool would be.
  3. There really isn’t anything revolutionary about a video lecture.  A recorded lecture is still just a lecture.  What’s critical here is guiding of the learning.  We are advocating Reading Guides for chapters or articles, quizzes and interactive questions for online modules, and short (5 minute) captured lecture bursts to guide readings, etc.  Can the students learn from a captured lecture?  Yes.  Can they learn better with additional or with other tools?  Absolutely.  Bergmann cautions that flipped learning is NOT “a synonym for online videos. When most people hear about the flipped class all they think about are the videos. It is the interaction and the meaningful learning activities that occur during the face-to-face time that is most important.”(Bergmann et al, 2011.)
  4. Are lectures “bad”?  Absolutely not!  Flipping makes room for another teaching method, or several of them.  But lectures have a place in medical education, especially for introducing a concept, generating excitement in a topic, providing a framework for learning, and other suitable purposes.
  5. It’s still about what happens in the classroom.  I used the word “inextricably” above—the independent student learning must be closely linked to what happens in class.  The class time is used to check on the student learning, clear up any questions, and work through well-thought-out and well-crafted group activities.  Student intra-group discussion, student inquiry, students debriefing to the whole class, and instructors providing feedback to students about their learning are important activities.  There is still a lot for an instructor to do in helping students to learn; it’s just been “flipped.”

Do you have questions or comments about “flipping”?  Write back to the blog.


Baker, J.W. (2000).  The Classroom Flip’: Using Web Course Management Tools to Become the Guide by the Side. Selected Papers from the 11th International Conference on College Teaching and Learning (11th, Jacksonville, Florida, April 12-15, 2000). Chambers, J.A., ed.

Bergmann, J. (2011). The history of the flipped class: How the flipped class was born [Web log post]. Retrieved March 24, 2013, from http://blendedclassroom.blogspot.com/

Bergmann, J. (2012).  The Flipped Class as a Way TO the Answers. Flipped Learning.  Retrieved March 24, 2013 from http://flipped-learning.com/

Bergmann, J. (2012). Flip your classroom : reach every student in every class every day. Eugene, Or. Alexandria, Va: International Society for Technology in Education ASCD.

Bergmann, J., Overmyer, J. & Willie, B. (2011). The Flipped Class:
What it is and What it is Not.  Retrieved March 24, 2013 from http://www.thedailyriff.com/articles/the-flipped-class-conversation-689.php

Houston, M. & Lin, L. (2012). Humanizing the Classroom by Flipping the Homework versus Lecture Equation. In P. Resta (Ed.), Proceedings of Society for Information Technology & Teacher Education International Conference 2012 (pp. 1177-1182). Chesapeake, VA: AACE. Retrieved from http://www.editlib.org/p/39738.

Kahn, S. (2011). Let’s use video to reinvent education. Speech presented at TED2011. Retrieved March 24, 2013, from http://www.ted.com/talks/salman_khan_let_s_use_video_to_reinvent_education.html

Lage, M.J., Platt, G. J., Treglia, M. (2000). Inverting the classroom: a gateway to creating an inclusive learning environment. Journal of Economic Education.

Team Based Learning Collaborative.  Getting Started.  .  Retrieved March 24, 2013 from http://www.teambasedlearning.org/starting.

Thompson, C.  (2011, August.). How Khan Academy Is Changing the Rules of Education. Wired. Last retrieved on March 24, 2013 from http://www.wired.com/magazine/2011/07/ff_khan/

Zappe, S., Leicht, R., Messner, J., Litzinger, T., Lee, H., (2009). “Flipping” the Classroom to Explore Active Learning in a Large Undergraduate Course. American Society for Engineering Education.


Posted on

Medical School Admissions: Unintended Consequences

The response to my last article on the topic of medical school admissions would suggest that there’s both interest and concern regarding our current processes. In addition to the very interesting responses that were posted, a number of practicing physicians and students communicated with me directly with similar insights. It seems clear from this feedback, and from our own experiences here at Queen’s, that the combination of high demand for medical school positions and the “ill-designed tools” I alluded to in the previous article is giving rise to consequences that are at least unintended and, in the worst case, undesirable. Examples of those unintended consequences:

Strategic selection of undergraduate courses and programs. Academic Records have always been the cornerstone of the admission process. However, lack of uniformity regarding course content and evaluation rigour between institutions (and even departments in the same institutions) has eroded their reliability. It’s widely appreciated that some universities and programs take pride in the demands they place on their students and the meaning of an honours grade. Students attending such institutions therefore put themselves at a competitive disadvantage, despite receiving what all would agree is an excellent educational experience. In addition some disciplines, such as English and the Humanities, rarely award marks above the mid 80’s. Postgraduate science courses tend to award higher marks than undergraduate courses in the same discipline. Although all these vagaries are widely appreciated, there is no acceptable or fair means to equilibrate these inequities. Consequently, students interested in pursuing medical school admission may be making choices based on strategic priorities rather than interest or natural aptitude.

Resume construction. Applicants perceive a need to ensure their non-academic resumes reflect interest in medical and humanitarian pursuits. Although such efforts are obviously laudable, they may be chosen for strategic rather than purely altruistic value, and come with the price of exclusion from other very healthy growth experiences. In addition, such experiences may not be equally available to applicants from diverse communities and socioeconomic backgrounds.

Commercialization of Medical Education. The large number of young people seeking admission to medical school have become an economic “market” and medical education has become a “commodity”. The $270 cost of writing the MCAT does not seem unreasonable, but must be coupled with the cost of preparatory material, preparation courses, travel to and from examination sites, and multiple examinations that many candidates undertake in order to ensure competitive results. University undergraduate courses in biologic sciences have increasingly taken on a distinctly “medical school prep” tone, to the point that program designations have evolved to terms that denote closer links to medical education (“health science”, “medical sciences”), even providing MCAT preparation as part of the curriculum and publishing statistics regarding the rate of medical school acceptance among enrolled students. Although such programs may be of intrinsic value, one wonders whether there is sufficient value and career opportunity for the majority of participants who will not be successful in their medical school applications. Finally, the steadily increasing number of international medical schools that are offering positions to students able to bear the financial burden and accept the uncertainties of postgraduate placement is a clear consequence of the mismatch between demand and positions in Canada.

Premature exclusion (or selection) of Medicine as a career option. Admission to medical schools is increasingly seen as the ultimate award for academic excellence. There is an emerging perception that only academically very successful students need apply and, conversely, that high academic success carries the expectation of medical school admission, almost as an earned right. Both perceptions are problematic. The former excludes (or at least fails to encourage) students on the basis of very early and likely unrepresentative academic experiences. The latter runs the risk that students will set themselves, and parental expectations, on a very determined career path with an incomplete understanding of the demands of that career or their own suitability.

Socioeconomic barriers. Many of the factors noted result in significant barriers to less economically advantaged members of our society. A 2002 analysis of medical school enrolments revealed that only 10.8% of first year students came from rural areas, despite the fact that 22.4% of Canadians live in rural settings (CMAJ 2002; 166: 1029-35). The same study showed that 17% of medical students came from families with household incomes over $160,000, although only 2.7% of Canadian households had incomes over $150,000. Conversely, 15.4% of medical student families had household incomes less than $40,000 in 2002, although 39.7% of Canadian households are in this range. Although such observations do not allow us to conclude that a “barrier” exists, it does appear that our students are drawn from the socioeconomically advantaged sectors of our society, and some of the observations noted above provide explanations for this trend.

I ended my previous blog article by posing the question “Do we have a problem?” Most of the respondents felt we do, based on the issues noted above, all of which suggest the system is neither fully accessible to all deserving applicants, nor fundamentally aligned with the values our society would expect of the medical profession. However, no one seems to question the integrity of the process, nor the quality of the students who are ultimately being selected to medical school. We’re therefore left with the much more difficult issue, specifically: What, if anything, are we prepared to do about it?

There would seem to be two potential options:

  1. Try to change the admissions system to correct or modify the various issues, or
  2. Expand the number of medical school positions to admit more applicants

Both are obviously quite complex and far-reaching. The first option would require directed approaches to each of the issues listed above. For each, strategies could be developed and, in many cases, have been implemented with some success. Examples of such strategies could include any or all of the following:

  • Adjustment of undergraduate grades to account for university or program “degree of difficulty”
  • Development of a more valid and aligned standard entrance examination
  • Greater scrutiny regarding the content and impact of non-academic experiences
  • More scrutiny regarding the content and outcomes of undergraduate programs
  • Development of more aligned pre-medical undergraduate experiences, perhaps linked to medical school admission
  • Provision of economic support to socioeconomically disadvantaged students seeking medical education
  • Stronger links with high school programs to ensure students are aware of the expectations of medical education and practice
  • Linkage of medical school admission with specific service requirements

These and many other options are controversial, highly complex to implement and individually incomplete solutions to the problems we’ve identified. In addition, we would be left with the fundamental issue of still not having enough places for what would be a slightly different, but no smaller applicant pool.

The second approach (increasing medical school positions) has, in Canada, been linked to considerations of physician supply. As thoughtfully reviewed recently by my friend and colleague Dr. Steven Archer, new Head of Medicine at Queen’s (http://deptmed.queensu.ca/blog/?p=266) and also by Dr. Reznick, Dean of Health Sciences (http://meds.queensu.ca/blog/?p=2072), this is a highly complex issue, with no clear data and considerable controversy currently swirling as to questions as fundamental as whether Canada is under or over-supplied with physicians. However, we might engage this issue somewhat differently if we reflect on two realities of modern medical education:

1. The MD degree historically designated readiness to engage medical practice. This has not been the case for at least 50 years. Although our MD programs all provide fundamental clinical training and experience, it is with the intention that students will transition to more intense and direct clinical involvement in their specialty based postgraduate years. In fact, graduates now require a minimum of two (and often up to 7) additional years of postgraduate training, predominantly based in clinical settings.

2. The major limitation to expanding undergraduate MD programs is the availability of appropriately supervised clinical practice experiences. Every medical school in Canada struggles with finding educationally rigourous clinical experiences for their students. The widespread development of regional programs and distributed educational models is largely a result of this challenge.

The logical possibility exists, therefore, to confine undergraduate medical education to foundational science, clinical science and clinical skills, leaving clinical practice to postgraduate training. It would therefore be possible to open undergraduate training to a much larger number of applicants. The “bottle-neck” in the system would therefore occur at the entry to postgraduate training, which would still be limited by clinical placement opportunities and tied to whatever information was available regarding societal requirements for physicians.

The advantages of such a program would be to allow a much larger number of students to enter what would be a shorter and much less expensive educational program, probably directly from high school. That program, properly constructed, would allow students to better understand the realities of medical education and practice, and allow for more standardized assessments on which postgraduate entry could be based. This provides an opportunity to repatriate many Canadians studying Medicine abroad. For students not successful in achieving postgraduate placements, such programs could, if appropriately constructed, provide a solid basis to pursue a variety of alternative career paths. Many of the socioeconomic barriers would be lessened.

Disadvantages are numerous, including loss of the supportive, patient and learner-centred atmosphere most medical schools currently achieve, and further dividing an already “siloed” medical education system. Such programs would, in essence, become more specifically designed pre-medical programs without assurance of admission to postgraduate training, and would require many graduates to seek alternative career paths. The very designation “M.D.” would fundamentally be devalued, unless an alternative application of the term were developed, possibly to be awarded at the end of clinical training.

And so, what began as a discussion of medical school admissions has evolved into a reconsideration of the entire educational paradigm, and the very meaning of the MD degree. I would personally find this approach highly unappealing as, I believe, would most Undergraduate Deans across the country.  So why raise it? Because the system is fundamentally flawed, the meaning of the MD degree has already changed substantially, and radical proposals have a way of focusing discussion, often toward useful ends.

I welcome your views.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education

Posted on

Making D.I.L. an important part of teaching

In our model of Small Group Learning (SGL), we ask students to prepare for the SGL class by independent study of a text, online module or lecture, directed by the faculty.  This “Directed Independent Learning” (DIL) is often used, but how well is it used?

If we view the DIL as a way to have a “second” teaching session with the students, this allows us to give support, explanations and/or a rationale for the reading or viewing they are doing.

A recent study advocated 10 minute “supportive” podcasts as a way to help students understand the purpose and the key concepts and terminology in a reading prior to a group learning task.  The instructors chose podcasts as a way to connect with students and allow them to listen anytime and anywhere.

Whether you use a podcast, or simply write in the Teacher’s Message in MEdTech, here are some possible aspects of “teaching” with readings you can incorporate in your “DIL” teaching.

  • An introduction that explains why the reading had been chosen and how it links with course content or upcoming tasks;
  • Guidance on the key elements in the assigned reading on which students should focus;
  • Elaboration of particularly difficult content, including different ways of phrasing or explaining essential theoretical concepts;
  • Background on any concepts new to students and not explained in the reading with the goal of creating a context for the reading;
  • Grounding questions described as “designed to help students relate the material to their personal/professional reality.” (p. 82) In other words, questions that encouraged students to think about how the material applied to their interests and circumstances.

What are your thoughts on using this as a method to connect with students outside the classroom?

Taylor, L., McGrath-Champ, S., and Clarkeburn, H. (2012). Support student self-study: The educational design of podcasts in a collaborative learning context. Active Learning in Higher Education, 13 (1), 77-90.

Posted on

Answers to questions about small group learning

We’ve received a lot of questions about how to make small group learning work smoothly for students and faculty.  Here’s one with some answers gleaned from the literature and from experience:

I always seem to end up talking a lot in sgl.  How can I let students talk more?

  • Learn to “teach with your mouth shut.” (Finkel, 2000).  Let the students do the work in their groups and let them take care of the debrief as much as possible.
  • As soon as students are in their groups, get them going on the tasks.  Stop talking.
  • Have faith in the students’ ability to get it, or to help others in the group get it.
  • Plan to speak about 25% of the time, and let groups take the rest of the 75% of the time.
  • In debrief, assign groups to answer.
  • Don’t respond to student answers in debrief, except to say “Thank you.”
  • Ask other groups for agreement, for other suggestions, for challenges or rationales.  If a wrong answer is given, ask the class or other groups if the answer is correct.
  • If there are questions, “Park them” for later discussion on the whiteboard, or to post answers to the MEdTech Discussion Board later that day in the session.
  • If it’s someone showing off their own knowledge by asking a question irrelevant to the class, ask to discuss after class. “That question shows you have a great deal of background in this subject.  The question is not relevant to the what the class needs to know but I’d be very glad to discuss it with you…Will you stay after class, or get in touch with me?”
  • Plan for a mini-lecture time slot (say 5-7 minutes) for you to explain denser or misunderstood topics.
  • Make sure that your activities for the group are challenging yet give the opportunity to learn.

Do you have more answers or other questions?  Please respond to this post!

Finkel, Donald L. & Finkel, Susan. (2000).  Teaching with your mouth shut.  Heinemann.


Posted on