Flipped education may help in the education of junior general surgery residents in their trauma rotation; a mixed-method study

Introduction: This study aims to assess the effectiveness of ipped learning in trauma rotation of rst-year general surgery residents. This method entails the use of books, podcasts, and movies prior to the discussion of the topics in the classroom/conferences. Method: All (n=15) junior general surgery residents in Shiraz medical school. In the quantitative phase of the study, 3 test scores were compared. All tests were composed of 20 multiple choice clinical scenarios. A pretest was done on the registration date. After that, the media (videos and podcasts) and books were given to the residents. One month later, the residents had a case-based discussion on the primary trauma survey. An early post-test was done immediately after the case-based discussion, and a late post-test one month following commencement of the program. Also, a semi-structured phone interview was done with residents by an external audit. Results: The was a signicant correlation between pretest (Mean=10.733,SD=2.25) and early post-test scores (Mean=12.8 ,SD=1.82) among residents (P=0.004) . Moreover, residents had a higher delayed post-test score (M=13.267, SD=1.53) in comparison to the pre-test (P=0.002). Surprisingly there was no signicant difference between early and late post-test (P=0.404). The resident was also satised with the overall usefulness of the program for junior residents (overall score 4/5). We did not nd any correlation between gender with the test scores. In the qualitative phase of the study, we noticed that our participants tend to use podcasts more than other materials. They believed that the videos and books help more to foster theoretical knowledge. The case-based discussion makes them more condent in dealing with the patients in their daily encounters Conclusion: Finding in this study reveals that ipped learning can be a useful, highly benecial platform and promotive for junior general surgery programs.


Introduction
The education of general surgery residents is complex and complicated. There are many areas to become an expert as a general surgeon. One of these is trauma, which is considered as a primary content area of general surgery residents by the American Board of surgery and other related committees [1]. This issue may be more complicated, considering suboptimal training of the residents because of duty hour restrictions [2]. Trauma is accountable for 20 percent of the global burden of diseases [3]. According to statistics, the trauma victim rate is more than the cumulative numbers of HIV, tuberculosis, and malaria each year. Moreover, trauma accountable for around 20 percent of the global burden of diseases. [4] This requires the immediate attention of surgical curriculum planners, mainly in the developing world, where the fth-sixth percent of mortalities are based on trauma. [5] Also, in the Emergency Room(ER), the patients' sensitivity and medical presentations necessitate immediate attention, obtaining a proper history and physical examination, precisely ordering rst line lab data and start management plan. Clinical management of trauma victims is realm of golden seconds/minutes [6]. In simple words, trauma is a surgical eld that seconds matter and not minutes. [7] Evidence showed that following the restriction in duty hours of residents and progression of subspecialty care, trauma training as one of the major core components of the general surgery curriculum has affected miserably [8]. This requires the adoption of unique and novel methodological approaches to enhance learning and compensation of the de ciencies in educational program. Moreover, the traditional concept of surgical education that the training merely occurs in the context of operation room is questionable as me moved forward to enhance e cacy and decrease the risks [8]. Also, education in residency programs differs from other types of training. The pedagogical approach is a traditional and widely known version of education, in which students learn and teachers teach [9]. On the other side, an andragogical approach promotes self-directed, problem-oriented, self-re ected, and learner-centered learning. In this methodology, the mentor/teacher merely facilitates learning. With such an approach, the role is didactic lectures are blurred, and more focus is on other types of learning such as problem-based learning (PBL), small group discussion, game-based learning, simulation-based learning. [10] The surgical education has many complexities as well; many new minimally invasive devices has been introduced in surgey during past few decades. Mastering this techniques and devices ,such as laparascopy, has turned to be an eseential in curriculum design.This provide an unique opportunity to integrate e-learning into the course plans [11]. Integration of any new educational strategy necessitates the proper recognition of cons and pros of the program. One of novel educational method which integrates the traditional "in-classroom" education with e-learning is blended learning [12]. This method is considered as a bridge from the traditional teacher domoinated face to face lectures/discussions to fully web based education [13].
The blended learning and especially ipped classroom arose from high schools and undergraduates of non-medical elds. However, this method progressed rapidly in many areas, including medicine. [14] In this method, teachers provide content of the curriculum in a balanced, targeted, and a rational salad of methodologies to the students. Some materials are provided in the movie, while others are in podcasts or books. Additionally, the students attend the case based/teacher facilitating discussions after processing that initial resources. [15]. Flipped learning is composed of e-Learning and didactic sessions, in which educational materials (books, podcasts, and videoclips) are provided a priori to the classroom discussion [16].
This method was rst used by Jonathan Bergmann and Aaron Sams in 2007 when they decided to provide audio narrated powerpoints for absent students in a chemistry course [17,18]. They de ned this kind of learning as "what which traditionally done in class now is done in the homes, and what which is traditionally done as homework now is done in the class." [17] In this approach, as all students are, at least, familiar with the concept of the topic, class time would be more useful to both high-ranked and mediocre ones [19]. Also, as it is learner-based and discussion-based, it would promote higher cognitive function such as analysis and critical thinking. [20] Flipped learning has emerged in residency programs to address the busy schedule of faculties and residents and help to robust effectiveness considering the restricted duty hours [5]. The application of this method is considered to be highly effective for junior residents. Because they are less experienced, quickly feel overwhelmed, and have high working stress, which may result in early burnout [21]. In designing a ipped curriculum for general surgery residents, teachers, and curriculum planners should design curriculum in a time-effective and exible manner that does not require to attend all classes in-site [22]. We suppose that the ipped method is the right way for education, especially in rst-year surgical residents, in this case, junior general surgery residents. Also, in the COVID-There is a wide gap in evidence concerning ipped learning in the medical curriculum, especially the post-graduate curriculum [26]. In the current study, we aimed to investigate the applicability of ipped learning in trauma education among junior general surgery residents in Shiraz medical school. We sought to answers four research questions: (I) can ipped learning foster knowledge acquisition? (II) can ipped learning lead to the encouragement of knowledge retention in trauma rotation? (III) how much is the use of material usage by our residents in ipped learning? (IV) was the overall program satisfactory to participants? To our best knowledge, it is the rst reported integration of ipped learning into the trauma rotation curriculum of general surgery residents.

Methods
This study was done with a mixed-method approach. The research sample was all of the junior general surgery residents of Shiraz medical school who were selected by the census method. After explaining the aims and methodology of study for them, all of 15 residents participated in our study. In this step, informed written consents were obtained from the residents. We assured them that their private information would be kept con dential.
In this study, all residents were in the intervention group (educated with ipped learning) with the use of pre-test, early post-test, and a late post-test design after four weeks. We aimed to assess the impact of ipped learning on clinical judgment and problem solving of rst-year general surgery residents of Shiraz medical school concerning the primary trauma survey. Then semi-structured phone interviews were conducted with the research samples to determine their quantitive use of material, perceived utility of the material, and overall satisfaction of the program. All the residents fully completed the study, and there was no missing data within the educational intervention.

Study design :
The study was designed in April and May 2019 with a collaboration between "Shiraz trauma hospital" and "o ce of Continuing education program" of Shiraz University of Medical Sciences. Their educational materials were composed of videos, rapid review podcasts, and books. The paper materials were from two  The implementation of the education program and evaluation phase lasted from September to November 2019. In September 2019, a pre-test examination was held to assess the baseline knowledge of the residents regarding the primary trauma survey. After that, all junior general surgery residents received educational movies, podcasts, and books for primary trauma surveys. One month later, a case-based discussion was held for residents in a 2.5 hours class discussion. In that class, the attendings reviewed the concepts of the educational materials by case-based teaching and interactive lecture. For assessing the early e cacy of the program in clinical problem solving, and early post-test was done after the case-based discussion. One month later (early November), all residents participated in a delayed post-test examination to assess the impact of the whole program in knowledge retention of the contents. In order to assess the higher level of cognition, pretest, early post-test, and late post-test, all were composed of 20 comparable clinical scenarios to evaluate clinical judgment and problem-solving capabilities [27]. In mid-November 2019, a semi-structured phone interview, using a ve score Likert scale, was conducted by an external expert. Each interview lasted around 20 minutes. The interviews were then transcribed and analyzed using qualitative content analysis.
Data collection tools : In the quantitative phase of the study, we used three comparable multiple choice question (MCQ) examinations as a pretest, early post-test, and late-post test. All composed of 20 clinical scenarios on the primary trauma survey. Each correct answer awards one positive score for the responder and a total score of 20. The content and face validity of the exams were con rmed by four content experts of the "Educational Developmental Center" of Shiraz University of Medical The tool used in the qualitative phase of the study was a semi-structured interview. The content validity of the structured interview form was validated by four content experts of the "Educational Developmental Center" of Shiraz University of Medical Sciences. The forms had ve main sections with related subsections. The residents were asked to rate the whole program, how much they used each material, the bene ts of each in knowledge acquisition/retention, and promoting con dence in decision making. The nal question was an open question to evaluate the bene ts/drawbacks of this model. Based on the permission of the residents, their phone interviews were transcribed verbatim and studied by the rst and corresponding authors and analyzed with qualitative content analysis. The appropriate text fragments were chosen. Following that, the fragments were labeled and sorted. At the nal step, utilizing these fragments, central themes were extracted. Where these authors were not in full agreement, the nal decision was made by the second author. Finally, eight main themes were extracted, which are available in table 3.
Evaluation phase : Data Analysis was mediated by SPSS statistical software (version 18, Chicago, IL, USA). The Mann-Whitney test, Spearman's rho, and paired T-test used where applicable. The study was con rmed by the Ethics committee of Shiraz University of Medical Sciences.

Results
One aim of the present study was to investigate the attitude of junior general surgery residents toward ipped learning. Another aim of the study is the impact of the ipped learning on the gaining and keeping of residents' problem-solving ability in the area of primary trauma survey. Of the 15 participants, 9 (60%) were male, and 6 (40%) were male. The mean age of the residents was 29 ± 3 years. In order to investigate the problem-solving ability, 20 multiple choice clinical scenarios were used to assess the competency of residents' problem-solving in the pre-test, early post-test, and late post-test (Table 2).  Level of signi cance considered as below p = 0.05 . Values are expressed with the mean and standard deviation The results of the test scores are available in the above tables. In each test, the mean and standard deviation of scores are provided. Utilizing the mann_whitney test, we found no correlation between the results and genders.
In the qualitative phase, residents were called by an external audit and answered the related question in the semi-structured form. The questions were mainly about the quantitative use of the materials, the overall gain of each material in the term of promoting theoretical knowledge, and bedside decision making. Moreover, they were asked to rate the program with a score of 1 to 5. The data are summarized in table 4.
Looking to the table number 4, in the evaluation of the qualitative phase of the study using the semi-structured interview form, the residents were satis ed with the overall usefulness of the program (overall score 4/5). The use and perceived bene ts of the materials are available in table 1. In the case of the videos, the average rate of the use of video was 1.93/5. But those who used video believed that the usefulness of the videos on the promoting of theoretical knowledge and increasing the con dence in bedside decision making was 3.33/5 and 3.67/5, respectively. Regarding the podcasts, the mean employment of the podcasts among residents was 5/5. The perceived gain of the podcasts on the knowledge and con dence in the management of the patients in real life was shown to be 4.33/5 and 3.6/5. In terms of the paper materials (books), the quantitative use of the books was 2.2/5, and our study showed that the rate of the respondents to the books o increase theoretical knowledge was 4.13/5, while the impact of the books on the clinical judgment was 3.38/5. Concerning the case-based discussion session, all the residents attended that particular session (5/5). They believed that the e cacy of that case-based discussion on their knowledge and bedside judgment was 3.93 and 4.4 out of 5, respectively. Lower use of the videos may be attributed to lengthy duration of them. As summarized in table 5, the nal question in our phone interview was an open question. We asked the residents to mention any other required points to improve the programs. After writing down all 15 interviews, these subjects were categorized into eight cardinal themes. Seven residents believed that the course was highly bene cial, and they suggested that this course should be held every 2-3 months in a progressive mode. Six residents believed that the interactive nature of the case-based discussion was excellent assistance for them to overcome their stress in real-life situations. While one resident believed that 2.5-hour discussion was not enough to have a good overview of the topics, he/she believed that the session should be around 2.5 hours to cover all topics. Five residents pointed out that they suppose the rst month of the residency program should be devoted to their preparation and making them knowledgeable and capable enough to deal with patients, while two residents disagreed with this. That two residents claimed that education happens in dealing with the patients, and they prefer to have ongoing educations while they are serving the patients on the clinical wards. In our qualitative study, ve residents were con dent that podcasts are a great asset for learning that they were a rapid review of essentials in a brief and informative way. They believed that they could listen to these audios while waiting for patients or going from one ward to another ward or in their leisure time, conveniently. One resident suggested that the case-based discussion settings can be with the presence of the senior residents, which helps the junior residents to use their experiences. The presence of the seniors can also facilitate the establishment of a peer near mentorship between juniors residents and senior ones (table 5). Regarding the timing, I suppose that the rst month of our training program should be a pure observership with no clinical posting. In that time, we should learn/review all "must-know" points and then attend the wards. This will make us more con dent when dealing with the patients 3,4,7,11,14 I suppose that we should not have a pure observership month lled with classes, because we will notice the importance of the knowledge if we see their practicality in the eld

12,13
The case-based discussion was done in interactive mode and was helpful to decrease our stress of patient contact 2,4,5,9,11,13,15 This method should be held every 2-3 months. The course should be in a progressive mode, starting with a primary trauma survey and go forward to more advanced care. 1,2,6,8,10,11,15 Podcasts were highly concise and too bene cial as we can review them when/where ever needed. 3,10,11,12,14 Videos were comprehensive and excellent for learning, but the duration of them should be more limited 4 Presence of senior residents as teacher assistants in CBD sessions may help us to have their experience as well and foster their mentoring role 8 The 2.5-hour class was not enough to review all essentials 3

Discussion
The result of the study showed that the students' problem solving and retention was signi cantly improved after the intervention. This nding is in parallel with other ndings, which showed the effectiveness of ipped learning in terms of knowledge acquisition in medical education [18,23,[28][29][30][31][32]. The results reveal that ipped learning is useful in the encouragement of deep and active learning [33,34] and school achievement [35]. The ipped learning or classroom is increasingly getting a reputation as a fascinating and successful instructional methodology. Evidence is still scarce in the utilization of ipped learning in medical education and especially surgical education and the eld of trauma. This is the rst paper which investigates the applicability of the ipped learning in the trauma for general surgery residents.
Moreover, in our survey, the retention of the knowledge was con rmed by a lack of difference between the early and late post-test. We believe that this occurred possibly because the provided materials were prepared according to daily encountered scenarios of our local trauma care. This may enforce contextual learning resulting in a comparable late post-test in comparison to the early post-test. As in our study, several surveys have proposed this method causes more satisfaction of participants, program directors, and may increase test scores in comparison to traditional methods [22,36]. Similar to other studies, this research also shows a high level of satisfaction among participants In a study by Tan et al., 96% of respondents were satis ed with the belief that their ipped curriculum in emergency medicine was over the traditional curricula. The participants believe that having the resources, in advance, encourages learning and is considered as a motivator [18]. Moreover, in a cohort study, it was shown that besides experiencing a higher level of satisfaction, medical clerks with ipped surgical curriculum were more interested in pursuing surgery as the prospective eld of the study and profession. [35] Another study by Liebert et.al in surgery clerkship showed that about 90% of students rated their ipped learning curriculum excellent or outstanding. Moreover, 84% of the clerks believed that other clerkships should adopt a ipped based curriculum [37].
Other studies have shown the effects of ipped learning in metacognitive skills [40]. One main reason is that in this method, the residents have the authority to manage resources, pace, place, and time which makes them capable of self-regulation and performance [18,34,41]. In our study, we found that the residents were highly satis ed with their curriculum and uniquely interactive case-based discussion. They found it was constructive in decreasing their stress in real patient encounters. Another study con rms these ndings as the participants believed that ipped learning and especially case-based discussion sessions could lead to a higher level of cognitive functions such as analysis and synthesis of knowledge [42,43]. Multiple papers concerning ipped learning support the effectiveness of case-based learning in these settings [19,44,45]. Cases based learning will foster higher-order educational objectives in bloom taxonomy and cognitive ladder. The cases can serve as a well-established infrastructure and scaffold in which reinforces and categorizes the concepts and knowledge.
Others believe that this method is helpful as it encourages constructivism in medicine. They suggest that ipped learning helps learners to build their knowledge based on the pre-class materials, the case-based discussion, and their clinical experiences. [17,46] One of our residents believed that the duration of the videos was lengthy; however, it was comprehensive. Our videos were 17 hours on 13 subjects (with an average of 1 hour for each topic and max 1.5 hours). We believed, as an improvement, all future video sessions should be limited to 1 hour. This nding is consistent with another study in which the authors nally decided to change the preparation time of the videos to 60 minutes following the commencement of their study [45,47]. Some experts believe that long videos can easily ll people's working memory, which has minimal capacity. However, shorter videos make the individual process the information actively and follow the change [48].
In this regard, we noticed that our participants tend to use podcasts more than other materials. It is possibly because of the nature of the podcast, which is remarkably shorter than the videos and more exible to use based on time and place. Our ndings are similar to another study in which synopsized materials such as podcasts were more favorable to be used by the participants [18].
Moreover, our residents believed that videos and books help more to foster knowledge. The case-based discussion ( CBD)makes them more con dent in dealing with the patients (table 2,3). It may be implied that the high rate of the CBD is potentially due to the preclass mind preparation of the participants, which encourages learning [16] and another proof of concept for ipped learning. We noticed that none of the materials result in better results, per se. But in accumulation, they led to a signi cant difference, which is proof of the concept for this method (Table 2). We believe the ideal framework should entail all of the formats of the materials and multiple strategies to cover numerous learning styles and meet the educational objectives of the program [49].
The high acceptability of the ipped learning in this study revealed the e cacy and utility of this method in the surgical eld and especially trauma. In surgical residency programs, different schedules of residents, limited educational times, and immediate need for care of trauma victims threaten proper, uniform, and synchronized education of residents. Flipping the education will help the residents to have an invaluable source of learning, which is always available to them.
This method also saves the time of instructors to repeat basic and repetitive facts. The latter help the surgical team to focus on more advances point of care details which is often neglected due to time constraint [18].
Limitation : Although our general surgery programs is one of the most signi cant general surgery programs in Iran, this study was in a single school with limited sample size. The high rate of the participants may mitigate the biases, but further investigations are required

Conclusion
We concluded ipped learning is invaluable where the pace of attaining certain competencies matters like trauma. In our study, participants had a high rate of satisfaction. The early and late post-tests were signi cantly higher in comparison to the pre-test, which was in favor of the e cacy of ipped learning in knowledge acquisition and retention. All educational tools have their related cons and pros, and we suggest that they should be provided in a salad. Further studies, with larger samples, are required to investigate the applicability of ipped learning in trauma.

Declarations
Competing interests: The authors declare no competing interests.