Participants and settings
Participants were third year medical students from the Universidad de Navarra (Pamplona, Spain). Medical curriculum in Universidad de Navarra is divided in six years (three pre-clinical and three clinical years). The curriculum is based on the achievement of competences. They were students from two consecutive years (219 in 2017-18 and 201 in 2018-19) who were enrolled in Pathophysiology course. Pathophysiology is a whole-year course divided in two four-month parts. The first part (September to December) includes cardiovascular, renal, respiratory and blood pathophysiology and the second part (January to April) includes neurological, endocrine and metabolism and liver and gastrointestinal pathophysiology. The faculties of this subject are members of the Department of Internal Medicine. In the first part, one of the staff members (JIH) teaches both Respiratory (RP) and Blood Pathophysiology (BP). At the end of the first part, in December, the students have an exam, and those who pass it with a qualification above 60 out of 100 do not need to be examined of this part in the final exam in May. This exam includes a test with 100 multiple-choice questions (25 of every of the four parts). The final score is obtained after subtracting one third of the number of wrong answers to the number of correct answers.
In 2018, a FC method was used to teach RP. Several days before each session, the students received 3-4 videos of 5-7 minutes for each lesson. The videos consisted in the same presentation the teacher gave slides given in the 2017 lectures (that were given as a master class) and an audio that was recorded for 2018 with the slides used in the lectures. The students were allowed to send an e-mail to the teacher asking for a more detailed explanation of the doubtful points. The schema for every 45-50 minutes subsequent session was: 1) a 5-minute review of the lesson explained in the last session through 3-4 multiple-choice questions shown by the app Socrative (www.socrative.com); 2) explanation of the lesson of the day (30 minutes), restricted to the students’ questions (sent via e-mail or asked in the classroom) and to the most important / difficult concepts according to the teacher’s criterion (20-30 minutes); 3) presentation and discussion of a brief clinical case (5-10 minutes); and 4) review of the lesson through the comment of the multiple-choice questions about it that had been included in the last year exam.
The same teacher explained BP, without using videos. The schema of the sessions was similar, but the explanation of the lesson of the day was given as a master class in a standard fashion. The students had the slides used for the explanation several days before the session. In 2017, the same teacher had explained RP and BP the same lessons, but all both were given as a master class in a standard fashion. The results of this year were used as control.
The staff members of the Department of Internal Medicine were also the teachers of General Pathology (GP) in the second year. This four-month course is an introduction to Pathophysiology and is mostly devoted to the explanation of Etiology and Pathogenesis of disease.
We studied whether the potential improvement in the results with the flipped learning were related with age, gender and previous academic performance, evaluated as the results obtained in General Pathology (above / below the median).
The students were offered a survey about the FC method. The response to it was voluntary and anonymous. They had six weeks to respond to it, between the end of the sessions and the publication of the results of the December exam, including Christmas holydays. The survey is presented in table 1.
The study was approved by the School of Medicine of the Universidad de Navarra and by the Ethics Committee for Research of the Universidad de Navarra (project 2018-112). Students were not compensated for their participation in the study. They did not give their informed consent. Data of the students were recorded in a coded database, without personal information.
All the statistical analyses were done with the software SPSS version 20. For all tests, a P value below 0.05 was considered as statistically significant. Continuous variables are expressed as mean (standard error of mean) and categorical variables as number (percentage). Comparisons between groups were done with the Chi-square test (categorical variables) and Student’s t test for independent series (continuous variables), after checking their normal distribution using the Kolmogorov-Smirnov test and their variance homogeneity with the Levene’s test. A P value below 0.05 was considered as statistically significant. In the analysis of factors associated to the improvement of the results after FC, Bonferroni correction was applied; thus, a P value below 0.017 was considered statistically significant for this analysis.