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.


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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.


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Using I.C.E. to build objectives and activities

It’s snowy and icy out–a perfect time to learn to use I.C.E. to build your learning objectives and activities for your courses and individual sessions. The I.C.E. model stands for “Ideas, Connections and Extensions,” and was developed by Dr. Sue Fostaty-Young and Dr. Bob Wilson here at Queen’s.  When you’re planning a session or a course, use the concepts of building from Ideas (or facts and recall), to Connections (higher order thinking processes of analysis and application) and to Extensions (even higher order thinking processes of evaluation and creation).  These will help you design activities that lend themselves to different levels of thinking and doing.

The I.C.E. Model:

Ideas Connections Extensions
Knowing about




  • Factual recall of basic information
  • Grasp of elemental concepts
  • (e.g. conventions, principles, procedures, trends, laws)


 Understanding how and why”




  • Recognizing general ideas across different contexts
  • Demonstrating relationships and connections among concepts
  • Connecting prior knowledge and experience


“Thinking Beyond”




  • Predicting future outcomes
  • Proposing solutions
  • Justifying a position
  • Evaluating outcomes
  • Designing or building something new
  • Changing contexts


 And, after planning the types of learning activities, here are some helpful verbs that will assist you in determining the learning objectives:

Verbs for I.C.E.

Ideas Connections Extensions







locate, recognize























Adapted from Fostaty Young, S. & Wilson, R.J. (2000). Assessment and learning: The ICE approach. Winnipeg, MB: Portage and Main Press.

Erickson, L. B. & Strommer, W.D. (1991). Knowing, understanding and thinking: The goals of freshman instruction. In Teaching college freshman (pp.65-80). San Francisco: Jossey-Bass.


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Blogs our medical students are using to learn: by Eve Purdy (Meds 2015) and Sheila Pinchin

When you think of medical students learning about medicine, you might think about lectures, textbooks, labs, small group study and even online learning modules.  BUT, did you know that our students are also learning through blogs?

Blogs, or “web logs” consist of postings by a person in chronological order with the ability for others to respond.  You’re reading a blog right now.  Our students read them too for all kinds of reasons and to access all kinds of material.  See below for Eve Purdy’s picks and some reasons our students are blogging through medical school.  For a great video on social media (blogging, twitter, etc.) see the Harvard Panel on Social Media at https://www.youtube.com/watch?v=_OdaDJ2PLmQ

What are your thoughts on learning through blogs?

Why are our students learning through blogs?

Blogs are ENGAGING and allow for knowledge sharing, reflection and debate not simply dissemination of facts

Blogs break down traditional hierarchies in which a medical student might feel intimidated to challenge a resident or attending on a concept or idea. Blogs not only prevent students from feeling intimidated but they create an environment where all are equals

Many good blogs will have links to primary literature that can help answer practical questions that come up in clinic;  blogs written by learners often address the same questions other students ask and then point in the direction of some good background papers

Blogs help students see the same information in different ways.  They allow learners to find ways to engage in ways that are most meaningful to them. By seeking out their own resources students find they are able to remember and recall information because they were responsible for going through the method to get there.

Often, the colloquial and entertaining way blogs are written make reading them easy and actually quite fun (urinalysis voodoo: http://boringem.com/2012/12/12/urinalysis-voodoo/)

Blogs are often inspiring, remind learners and faculty why we are doing what we are doing

Students turn to blogs to address some needs that are not always met or to augment resources in the curriculum (ie learner wellness http://wellnessrounds.org)

People who write blogs generally aren’t getting much (or any) scholarly credit which means they are doing it because they WANT to. Bloggers take a great deal of pride in presenting information in new, helpful ways and once they find a target audience or niche are very good at what they do. They are quick to adapt to feedback and to incorporate/synthesize new information in ways that traditional outlets (journals and textbooks) cannot.

Examples of students learning through blogsEve Purdy’s gives us some picks:

– I’m in the ER and see a patient with something that might be atrial flutter but isn’t quite sure so I pull up this quick, easy to reference article on atrial flutter from “life in the fast lane” (one of the best blogs out there) http://lifeinthefastlane.com/ecg-library/atrial-flutter/ It gives a nice, simple review of information quickly without having to log in to my queensu/bracken library account (something that takes about 30 seconds- an amount of time that doesn’t seem like much written down but makes a big difference if you are referencing a bunch of things throughout the day)

-Learn the same topic through multiple lenses.  For example….a student is interested in learning more about a patient with chest pain.  If you prefer clinical cases check out (http://lifeinthefastlane.com/education/clinical-cases/) or you like videos like the Khan academy use (http://academiclifeinem.blogspot.ca/2013/01/patwari-academy-videos-low-risk-chest.html). There are many resources to turn to and the people who keep blogs generally like to teach so the format is student friendly.

-Students don’t just read blogs to learn about content. The advantages of reading blogs goes much deeper and serves to address much of the hidden curriculum, thoughts about careers, tips and tricks for medical school success, health policy and once in a great blog post while inspire us to be better medical students and doctors in ways that traditional resources cannot. I think this is probably the most common reason that students read blogs. There are a bunch of examples but a few are:

careers (http://wellnessrounds.org/choosing-your-specialty/ or http://boringem.com/2013/01/16/carms-game-time-the-interviews/)

tips and tricks (http://boringem.com/2013/01/02/top-10-ways-to-rock-em-clerkship/http://www.kevinmd.com/blog/2011/10/nurse-offers-medical-student-sage-advice.html)

social issues in medicine (http://emergencycarecanada.com/2013/01/14/non-urgent-patients-in-the-er-a-non-problem/)

just for fun (but really do more like address the hidden curriculum and remind us why we are here) http://www.medicalaxioms.com or http://doccartoon.blogspot.ca



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Congratulations to Drs. Ted Ashbury and Heather Murray

Congratulations to Dr. Ted Ashbury (Anesthesia) and Dr. Heather Murray (Emergency), both of whom are very involved in Medical Education!  They have been awarded the Canadian Association for Medical Education (CAME) Certificate of Merit, which promotes, recognizes and rewards faculty committed to medical education in Canadian medical schools.

In Undergraduate Medical Education, Ted has developed and is the Course Director for Professional Foundations 2 and 3, pre-clerkship courses which teach about the intrinsic or non-medical expert roles of a physician.  He has also served as the Competency Lead for the Professionalism Role since the inception of the Competency Lead Role.  Ted has also served as a founding member of the UGME Curriculum Committee.

In Undergraduate Medical Education, Heather developed and is the Course Director of Critical Appraisal, Research and Learning (CARL) and the Critical Enquiry Course in pre-clerkship UGME.  She is also the Competency Lead for the Scholar role from years 1-4 and serves on the UGME Curriculum Committee.

These deserving colleagues will be recognized at the upcoming CAME Annual General Meeting which is held in conjunction with the Canadian Conference on Medical Education (CCME) in Québec, QC on Sunday, April 21, 2013 at 17:30 at the Hilton Hotel Québec. Please join us in congratulating these individuals for their commitment to medical education in Canada.

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Many thanks for tremendous work: Farewell but not goodbye

Dr. Stephanie Baxter,  has moved from her position as Co-Course Director   for Neurology and Ophthalmology in Undergraduate Medical Education to serve  as the new Residency Program Director for the Department of  Ophthalmology.  She has also therefore left her position on the UGME Teaching and Learning Committee of which she was an inaugural member.

It’s difficult to express all that Stephanie has quietly accomplished in undergraduate medicine–from piloting the extremely successful Ophthalmology Skills Fair to complete course revision as she acted as one of the first exemplars of creating balanced teaching methods.  Stephanie has served the Teaching and Learning Committee well for 5 years, representing clinical teaching and supporting initiatives through her own teaching practice.

Perhaps most telling, however, is Stephanie’s contribution to student learning. She is the recipient of the 2011 Aesculapian Society’s Lectureship Award, and has already made an impact with her work in teaching residents, winning the Garth Taylor Resident Teaching Award of 2012, both attesting to the way Stephanie is able to interact with students to help them learn.

We wish Stephanie well in her work in Post Graduate Medical Education, and hope that our undergraduate students will still have the benefit of her teaching.  Many thanks Stephanie, for all your tremendous work!

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What do p and R-values mean anyhow? : Understanding how to interpret multiple-choice test scores using statistics.

Have you ever wondered whether or not your multiple-choice questions (MCQs) are too easy? The answer to this question can be found in the p-values or item difficulty: the percentage of students who answered correctly. The difficulty of a MCQ can range from 0.00 to 1.00; the higher the p-value, the easier the question. What we should be concerned with are high difficulty questions with p-values less than 0.3.

Have you ever wondered which questions tricked students who otherwise performed well on a test overall? The R-value or item discrimination looks at the relationship between how well students performed on a question and their total score. Item discrimination indicates students who know the tested material and those who do not. The higher the R-value, the more discriminating the test question. We should try to remove questions on the test with discrimination values (R-values) near or less than 0.3. This is because students who did poorly on the test did better on this question than students who performed better overall.

Did you Know?

Multiple-choice questions that use words in the stem such as best, most, first, or most correct require higher-level thinking but often confuse students because they are ambiguously worded. Our students have struggled lately with ambiguity in the wording of MCQs on RATs and exams such as “Which is the most likely….”. They assume “most likely” to be “most common”, whereas the most likely answer could be an uncommon situation. It’s important to word the question clearly so that students are not confused. So for example, the question could state, “In light of the clinical information provided above, which diagnosis would you make?

You can also ask students about “most common”, “most concerning”, or “what is the first test you would perform” etc. but it is always good to anchor these stems by referring to the data presented previously. Then the key is to require them to choose, evaluate, interpret, judge, infer from data, solve problems, and apply principles.

Did you Know?

The Student Assessment Committee has posted several articles, checklists and PowerPoint slides to assist you with Multiple Choice Questions.

For more guidance on writing high-quality multiple-choice questions refer to MCQ Guidelines and Writing MCQ’s in School of Medicine Faculty and Staff Resources at:






Queen’s School of Medicine: Faculty and Staff Resources.

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Translating students’ comments on course evaluations

Navigating students’ comments could be one of the most challenging aspects of interpreting course evaluations. In an article in Innovative Higher Education, Linda Hodges and Katherine Stanton (2007) suggest using these comments as “windows into the process of student learning and intellectual development” rather than as reviews of “how they have been entertained” by an instructor.

Hodges is Director of the Harold W. McGraw, Jr. Center for Teaching and Learning at Princeton University; Stanton is the center’s assistant director. They point out that sometimes students’ comments stem from “students’ expectations of or prior experiences with college classes” that “entail teachers standing in front of the room ‘telling.’”

For example, is a comment like “I did not learn in this class because the teacher did not teach” evidence of a lack of effective teaching, or evidence that the style of teaching – including lots of team-based work – wasn’t what the student was expecting? Reframing student comments in this light can ultimately help improve teaching, Hodges and Stanton suggest.

“We may see our evaluations less as judgments of our performance and more as insight into our students’ intellectual growth—insight that may engage us in intellectual growth as teachers and scholars.”

Hodges, L.C., and Stanton, K. (2007). “Translating comments on student evaluations into the language of learning” in Innovative Higher Education 31:279-286.

 Permalink: http://resolver.scholarsportal.info/resolve/07425627/v31i0005/279_tcoseitlol


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Can Students Multitask?

You may have noticed an occasional student referring to his Facebook page, or her ipod or ipad while also apparently listening to your lecture, or working with her/his team-mates in small group learning.  They are multitasking, as part of the “M” generation.  But are they really multitasking?  And is it working for them as successful learners?  Dr. MaryEllen Weimer has collected evidence in her article that students compromise their learning by multitasking and suggests we present them with the evidence to help them re-evaluate their approach to learning.  For a synopsis of the research she has collected, go to Faculty Focus.

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RATs (Readiness Assessment Tests): To time or not to time?

A very recent study at Regis University School of Pharmacy, which won best poster at the Team Based Learning Cooperative’s Annual Meeting, determined that students preferred timed tests vs. tests with no time limits.  Students also indicated that they preferred to be told that five minutes remained once fifty percent of the class had completed the iRAT (variable time limit) vs. being informed of the ttal time allotted to complete the iRAT (defined time limit).  (Richetti, C. et al, 2012)

This has value for us to explore.  The investigators were addressing the problem of “down time” in RATs where some students have finished and others have not.  Of the students surveyed (74) 97% responded to suggest that using the strategy of variable time limits was useful, and not likely to induce as much anxiety as the defined time limit.

Why not try this method with your students when you give a RAT?  Carefully observe, (and if there is another facilitator with you, use her/his observations) to determine when half the class has completed the RAT.  Some of our faculty ask students to raise a hand when the group or individual has finished a RAT, or use some other signal like a green card attached on their group clipboard.  That will enable you to give a “5 minute warning” to the rest of the class.

If you try this, please let us know what your findings are.

By the way, the investigators also found some additional benefits of timing RATs from their survey:

Our survey determined that the timing of iRATs decreases “down-time”, helps students increase their confidence in their ability to perform well on timed exams (e.g. board exams) and provides more time to focus on applications[tasks]. While students reported an increase in anxiety caused by the timing of iRATs, they reported they preferred the timed iRATs over the iRATs that were not timed.

Richetti, Charlotte, Brunner, Jason M., Fete, Matthew, Luckey, Stephen. & Nelson, Michael. (2012). “Student Perceptions on the Value of Timing Readiness Assurance Tests.  Poster presented at TBLC Annual Meeting, St. Petersburg.


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