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JAOA/AACOM Medical Education  |   October 2018
Using the Flipped Classroom With Simulation-Based Medical Education to Engage Millennial Osteopathic Medical Students
Author Notes
  • Financial Disclosures: None reported. 
  • Support: None reported. 
  •  *Address correspondence to Bernadette Riley, DO, Associate Professor, Department of Family Medicine, Director, Ehlers-Danlos Syndrome/Hypermobility Treatment Center, New York Institute of Technology College of Osteopathic Medicine, Northern Blvd, PO Box 8000, Old Westbury, NY 11568-8000. Email: briley@nyit.edu
     
Article Information
Medical Education
JAOA/AACOM Medical Education   |   October 2018
Using the Flipped Classroom With Simulation-Based Medical Education to Engage Millennial Osteopathic Medical Students
The Journal of the American Osteopathic Association, October 2018, Vol. 118, 673-678. doi:10.7556/jaoa.2018.147
The Journal of the American Osteopathic Association, October 2018, Vol. 118, 673-678. doi:10.7556/jaoa.2018.147
Abstract

With advances in technology and the advent of social media and social networking sites, the way medical education is taught to millennials must evolve. The “flipped classroom,” which occurs when students are exposed to learning materials before their assigned face-to-face class or didactic session, can help engage all learning styles. A flipped classroom paired with simulation-based medical education (SBME) engages millennial learners to acquire the large amount of information required in osteopathic medical school. Using this paired approach in osteopathic medical education can help students meet the requirements outlined by the Accreditation Council for Graduate Medical Education (ACGME). With the single accreditation system for graduate medical education, finalizing in 2020, this article proposes mandating a flipped classroom with SBME to better prepare osteopathic medical students for their training in ACGME-accredited programs.

The millennial generation of osteopathic medical students has different learning styles than prior generations. The millennial learner tends to incorporate technology and thrive in a “learning-centered environment” rather than in traditional undergraduate didactic sessions.1 Indeed, the traditional lecture with Microsoft PowerPoint slides is now being questioned as to its relevance and importance in undergraduate medical education.2 Instead, a “flipped classroom” with simulation-based medical education (SBME) allows millennial learners to engage their self-directed learning style and address their need for up-to-date information.1 Such student engagement is paramount for millennial learners and their retention of information.2 
In July 2020, all graduate medical education (GME) programs will be accredited by the Accreditation Council for Graduate Medical Education (ACGME) under a single accreditation system. Some ACGME-accredited programs, such as surgery,3 require the use of simulation during undergraduate training, which is not the case for current programs accredited by the American Osteopathic Association. Simulation-based medical education is a method of learning that incorporates high-fidelity simulators and/or standardized patients to simulate a medical case or patient, allowing medical students to practice their clinical skills before encountering a real patient. These sessions are engaging and interactive and incorporate “active learning with emotional connection,”1 which allows learners to apply the knowledge gained in simulation training to real cases. 
With the rapidly expanding information regarding millennial learning capabilities and preferences, and with ACGME's expectations for simulation training experience, osteopathic medical schools must evolve to engage and meet the needs of younger learners. As discussed in this article, a flipped classroom with SBME allows for all of these requirements to be fulfilled and thus should be mandated in osteopathic medical education. By effectively using technology through a flipped classroom and SBME model, osteopathic medical students can thrive. 
Millennials and the Flipped Classroom
The accountability factor is one of the reasons why the flipped classroom is an appropriate way to educate osteopathic medical students from the millennial generation. Although the birth years vary depending on the source, generally, millennials were born between 1982 and 2002. Because they grew up in the early years of digital technology, including online communication and social media, they are considered “digital natives.”4 Millennials also tend to be distracted more easily, which can impede learning through traditional lecture models.4 As a result, millennials crave active learning methods that challenge them and offer the ability to control the pace of their learning.4 A flipped classroom can provide all of these aspects of learning. 
For example, a video module, videotaped lecture, or active learning session before a face-to-face encounter helps millennial learners stay active to the tasks at hand. A flipped classroom also allows students to replay a part of a lecture or modules they would like to learn again if needed.4 Because the flipped classroom is “student centered,” millennial learners can fully engage and be in charge of their own learning.5 People who tend to succeed in the flipped classroom have high levels of self-motivation.6 Although intrinsic motivation is innate, “the maintenance and enhancement of intrinsic motivation depends on the social and environmental conditions surrounding the individual.”7 Allowing the millennial learner freedom to participate in learning before in-person sessions gives them autonomy and allows them to view the subject matter in their own time and space and learn at their own pace.8 The face-to-face part of the flipped classroom then encourages deep and meaningful interaction with others, allowing for high order of thinking.9 The need for peer-to-faculty interactions is imperative in medical education, and this interaction occurs in the flipped classroom.10 
Responses from students have been positive, with surveys showing that most millennial students have enjoyed their experience with the flipped classroom method of teaching.11 For example, in one survey,12 millennial students preferred the variety of learning formats that the flipped classroom provided. 
How Does the Flipped Classroom With SBME Work?
In SBME, the flipped classroom is incorporated when learners are given videos or pretests before a simulated case to prepare them for the learning objective of the session. During the simulation or face-to-face environment, the learners “engage in experimental learning through simulation of various sorts.”13 During the debriefing phase of SBME, the learners can react and reflect on their practice while they absorb and retain information “at their own pace and perhaps have a choice of methods by which to achieve cognitive learning objectives.”13 Thus, learners identify how they perceive, process, and learn the information they are provided and experience.14 
Using the Flipped Classroom With SBME to Engage Learning Styles
Millennial students have different learning ideals than other generations, such as Generation X, which is not as technologically advanced. The flipped classroom allows for multiple learning styles for students to obtain knowledge.14 Millennial students may want or expect the incorporation of technology and visual learning aides to improve their learning.14 For example, a study of graduate pharmacy students showed they had better recall and did better on a test after exposure to both a “flipped classroom format and a virtual patient case.”15 
Incorporating the Flipped Classroom With SBME in Osteopathic Medical School
Flipped classrooms are useful during clerkship years when osteopathic medical students are geographically spread out and cannot immediately convene at a given location. Flipped classrooms are especially beneficial during hospital rotations, where students are expected to have an extraordinary amount of medical knowledge to apply in clinical settings. Before their rotation, students can be emailed information, videos, and modules that they can review before their rotation. This is especially valuable in subspecialty areas, where specific information needed is often not detailed during preclinical training. One study in China showed that when an ophthalmology module was given to students before their rotation, students in the flipped classroom had higher scores on a posttest compared with students in the traditional group.16 However, in another study, Carrick et al17 showed that a group of students who took a neuro-otology curriculum online (representing the flipped classroom) received similar scores on posttests as those who were assigned to the traditional classroom experience. 
Williams18 noted that during the face-to-face interaction of a flipped classroom, one of the only skills not taught was bedside manner. Simulation could help fill this gap. During the simulated session of a flipped classroom, the osteopathic medical student would be exposed to a case on the subject they were learning. This case would be videotaped and recorded and reviewed with a faculty member who would discuss how it relates to clinical practice. Such a session would allow for a learning-centered paradigm that the millennial learner craves.4 As stated in a Simulating Healthcare article,13 “the face-to-face time that students spend together in conjunction with faculty members is generally the most expensive time,” and therefore, it should maximized. Furthermore, SBME may help osteopathic medical students pass licensing examinations. Sandella et al19 found that students who had a prerequisite SP examination at their school were more likely to pass the Comprehensive Osteopathic Medical Licensing Examination-USA Level 2-Performance Evaluation. 
Procedure-driven specialties such as surgery can use SBME and the flipped classroom as an avenue for students to practice surgical procedures. Chiu et al20 found that medical students who participated in a simulation-based flipped classroom were able to suture better than their counterparts in traditional classroom settings. In a study by Liebert et al,21 medical students on their surgery clerkships who were exposed to a simulation-based flipped classroom felt more prepared for their shelf examinations and agreed that the “environment fostered accountability and self-directed learning.” These results suggest that by incorporating SBME with a flipped classroom, medical students can learn procedure-based skills as well as enhance their medical knowledge.22 Likewise, by using SBME, the ACGME simulation requirement that exists for some specialties can be met.23 
Flipped Classroom and Graduate Education
Considering medical education also involves lifelong learning, it is important to examine how the flipped classroom affects GME. An osteopathic medical student is preparing to enter the GME world from the first day of osteopathic medical school. When that student enters GME, he or she must be prepared and ready for learning curves and the exponential knowledge growth seen in residency programs. Emergency medicine residency programs have studied the flipped classroom and have used the idea of filmed lectures, modules, and simulations with positive results.24 Young et al25 tested the idea of a flipped classroom on Loma Linda ACGME-accredited emergency medicine residents and found that most residents preferred this learning environment. Anesthesiology interns26 and residents27 also have responded favorably to a flipped classroom method. A study of 143 internal medicine residents who were exposed to a flipped classroom at the Mayo Clinic had “improved scores after curriculum exposure and associations with greater engagement in online modules.”28 They also had improved quality improvement knowledge.28 
Residency programs are expected to prepare residents for practice by developing competencies in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice.29,30 Journal clubs are common tools to enhance practice-based learning and improve overall competency of residents. Journal clubs can be seen as flipped classrooms, where the learner is given an article before an intense face-to-face dissection of the article at a later date. Rucker et al,31 however, described how a family medicine residency expanded their journal club by embracing a flipped classroom model and posting online discussion modules with more interactive case vignettes. Instead of the face-to-face meeting being a long account of the article, discussions were able to begin immediately, bringing clinical patient demographics to the forefront.31 
Cooper et al32 highlight the differences in the flipped classroom in the undergraduate and graduate levels of medical education. During undergraduate training, medical students’ main responsibility is to study and engage in testing; during GME training, learners have a larger clinical responsibility and must take time to develop their practical skills as well as continue learning. Although the outcome of the journey is the same (to be a competent physician), getting there while facing day-to-day challenges can be an issue. Cooper et al32 suggest giving residents incentives to help motivate them for learning in a flipped classroom model. This incentive can not only help motivate the learner, but can also hold the learner accountable for participating in the flipped classroom. Patanwala et al33 found that pharmacy students did better in a flipped classroom setting when they knew a posttest was involved than if there was no test.33 
The flipped classroom has also been used in other sectors of graduate education. Nursing education programs have found “neutral or positive outcomes.”34 Masters of public health programs have used the flipped classroom with positive results,35,36 as has veterinary science education.37 
Dealing With Challenges and Change
Although most osteopathic medical schools have simulation laboratories that could be used with the flipped classroom, the financial costs of increasing technology, developing online modules or videos, and training faculty in the new curricular model may still be a barrier. Technological issues in particular present a challenge to the flipped classroom.38 Making sure osteopathic medical students have access to proper technology to be able to participate in the pre-class assignments, regardless of their financial situation, is important to avoid introducing economic disadvantages. Moffett39 offers 12 tips for “flipping” the classroom. For example, she recommends using technology already available as a money-saving strategy.39 Another suggestion is to “remember that a flip does not have to be ‘all or nothing.’”39 These changes can occur gradually, which is especially important to remember in the early stages of a flip when faculty and learners may be hesitant. 
Over time and with effort, the curriculum will come together and provide a variety of learning options for students. As noted by Roehl et al,4 “The introduction of any new strategy requires a shift in the minds of both educators and students.” The faculty will need training sessions and development sessions to assume the role as facilitator and mentor to the students during the face-to-face time. The faculty in charge of the debriefing portion of simulations will also need training and instruction. An important part of making the flipped classroom successful is to appropriately point out the expectations for the results of the course for both the student and educator.40 Millennial learners will likely have a smooth transition to the flipped classroom and SBME, as they have been exposed to online learning and technological tools. 
Although there will be an initial increase in financial investment for at least the first year of the flipped classroom with SBME, the costs should eventually decrease. As described by Persky and McLaughlin,8 “by blending the strengths of computer-mediated instruction … and face-to-face class time…, the flipped classroom can improve student outcomes, increase student engagement, and enhance critical thinking development.” Thus, the changes and investments will be invaluable to the success of the program.41 
Conclusion
As the millennial learner has adjusted to “disruptive innovations,” so must osteopathic medical education.42 By osteopathic undergraduate medical education using a flipped classroom in the curriculum, students can feel engaged in their learning while also controlling the pace of medical knowledge.42 With the single accreditation system finalizing in 2020, the time is now to adapt to a flipped classroom with SBME as a standard for teaching osteopathic medical students to meet the ACGME requirements and to succeed in ACGME-accredited residencies. 
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