Implementation of the POGIL-based ipped classroom learning: an approach to promote learning in emergency medicine

Background: As the Emergency medicine is a multidisciplinary discipline, the emergency medicine education is focuses on teaching students to think actively. The ipped classroom was widely used in various medicine teaching that can improve the ecacy of classroom learning. While the process-oriented guided-inquiry learning (POGIL), which be proved can promoting active learning and critical thinking.We assume that both two teaching methods may complement each other in emergency medicine education. Object: To evaluate the student’ learning effectiveness and acceptability of the process-oriented guided-inquiry learning (POGIL)-based ipped classroom model for teaching emergency medicine education. Methods: A total of 90 students majoring in clinical medicine at Xiangya School of Medicine, Central South University, were enrolled in this study. They were randomly divided into an experimental group and control group, with 45 students in each group. The experimental group adopted the POGIL-based ipped classroom model, and the control group adopted the traditional teaching model; teaching effectiveness was evaluated through tests, an operation exam and questionnaire surveys. Results: After the completion of the course, the scores of the two groups were compared. The theoretical and operational scores of the experimental group were higher than those of the control group, and the differences were statistically signicant (P < 0.05). The learning interest, clinical thinking ability, and acceptance of the teaching model for the students in the experimental group were signicantly higher than those for students in the control group, and the differences were statistically signicant (P < 0.05). Conclusion: The POGIL-based ipped classroom model can signicantly improve students' scores, students' acceptance of the teaching model, and teaching quality.


Background
Emergency medicine is a new interdisciplinary eld in clinical medicine and covers 22 medical specialties, including internal medicine, surgery, obstetrics and gynecology, pediatrics and infectious diseases. Its teaching focus is to train students to evaluate and deal with various complicated and changeable conditions of emergency patients in a short time, and students are required to master comprehensive clinical knowledge and have active divergent thinking; therefore, learning and teaching this course are more di cult than they are for other medical courses [1].
In China, the traditional teaching model for emergency medicine uses PPT and adopts the "cramming" method. Teachers are unable to re ect the "urgency" and "complexity" of emergency medicine through limited teaching time. Students passively receive knowledge, have insu cient independent thinking and have limited learning enthusiasm [2]. In clinical practice, when facing patients with the same clinical manifestations but different causes, it is impossible for students to apply knowledge learned from books to real cases. Therefore, teaching emergency medicine has always been a di cult and weak point in clinical medical education. Despite the use of problem-based learning (PBL), computer-based learning (CBL) and even team-based learning (TBL) to assist in various teaching models, the differences in students' learning ability and knowledge background cause inconsistent teaching effects [3][4][5].
Improving the critical thinking ability of students and increasing students' interest in learning emergency medicine have become urgent issues in the reform of the current emergency medicine teaching model.
Process-oriented guided-inquiry learning (POGIL) is a new student-oriented teaching method. In this teaching model, situational teaching is integrated into the classroom to guide students to explore and learn, in order to train students to think creatively and to use knowledge purposefully [6]. In recent years, the ipped classroom method has been shown to effectively stimulate students' interest in learning and improve students' independent thinking, practical skills and ability to collaborate. Therefore, to improve teaching effectiveness, we, for the rst time, applied an innovative POGIL-based ipped classroom model for teaching emergency medicine and analyzed and compared the teaching effects between this new teaching model and the traditional teaching method, in order to explore a new model for teaching emergency medicine.

Participants
A total of 90 fourth-year medical students majoring in clinical medicine at the Xiangya School of Medicine Central South University were enrolled.Among them, 40 were eighth-year medical students, and 50 were fth-year medical students (2015 class); 38 were male, and 52 were female. They were randomly divided into an experimental group and a control group, with 45 students in each group. General information regarding the students in two groups was comparable, and differences were not statistically signi cant (P > 0.05), as shown in Table 1.

Study design
Teaching methods The emergency medicine program content includes cardio-pulmonary resuscitation (CPR) and electric de brillation and treatments for trauma, acute chest pain, acute abdominal pain, poisoning and other common critical illnesses. The teachers in the two groups were the same and were senior attending or associate professors with extensive clinical experience. The traditional teaching model was used in the control group. For the experimental group, the POGIL-based ipped classroom model was adopted, in which the teachers prepared videos related to the teaching content and sent them to the students before class so that the students could watch the videos, be familiar with the cases, read related literature, and raise their own questions. The instructors also prepared targeted problems based on the selected cases and required competencies, including case characteristics, diagnosis and differential diagnosis, examination and treatment. In the class, the students were asked to discuss questions related to the selected cases in small groups rst; then, one representative student from each group answered the questions, and the instructors guided the students in writing a summary. In this way, the students could fully grasp and integrate all emergency medicine content and increase their ability to solve problems independently.

Data evaluation
Evaluation criteria After the completion of the course, the two groups of students were assessed, including the students' grades and satisfaction with the teaching method. All students took the same tests: theoretical tests (100 points), operational skills (100 points) and teaching satisfaction questionnaire (10 points). The questionnaire included six aspects: critical clinical thinking, enthusiasm toward learning, ability to analyze and solve problems, solid grasp of the content, teamwork ability and acceptance of the teaching method.
Teaching quality statistics After the completion of the course, 90 students took the same test and operational assessment. The test and assessment were conducted by the same senior lecturers, and the nal results were statistically analyzed.

Satisfaction survey
Comparison of other aspects of the teaching methods There was no signi cant difference in knowledge gained between the two groups of students. For the medical students in the experimental group, critical clinical thinking ability, enthusiasm toward learning, the ability to analyze and solve problems, solid grasp of the content, and acceptance of the teaching model were signi cantly higher than those of medical students in the control group, and the differences were statistically signi cant (P < 0.05), as shown in Table 2.

Discussion
Emergency medicine is a special interdisciplinary eld and covers a large number of medical specialties. In clinical practice, emergency patients present with acute and complicated diseases, including some occult diseases, which require clinicians to have comprehensive clinical knowledge and to have the ability to use that knowledge to screen and diagnose various diseases. Therefore, the training of students in emergency clinical medicine is more demanding [7]. In view of the challenges of teaching emergency medicine, we used the POGIL-based ipped classroom model to teach emergency medicine, in order to train students in active divergent thinking when learning emergency medicine.
The ipped classroom model is a new type of teaching model in which learning of general knowledge is performed by students before the class, but in-depth teaching, case studies and problem solving are conducted in the class with instructors [8]. The ipped classroom model restructures students' learning process, and information/knowledge transmission is carried out before class. The teacher not only provides videos but also provides online tutoring. Understanding the content is accomplished through interactions in class; additionally, teachers can know students' learning di culties in advance and provide effective guidance in class. Communication among classmates is encouraged to promote learning by the students. Studies have found that in many other clinical medicine courses, the ipped classroom model can effectively stimulate students' interest in learning and improve students' critical thinking, practical abilities and ability to collaboration [9].
POGIL is a new student-centered teaching method. This teaching model uses situational teaching as the starting point and inquiry learning as main learning strategy. To gain knowledge regarding basic concepts, students are encouraged to study in groups and work in teams, aiming to increase students' innovative thinking ability and the ability to apply knowledge in new elds. The goal is to enable students to participate in the learning process and develop important clinical skills through learning and understanding basic concepts. Studies have shown that the "cramming" method is not suitable for most students and that students in interactive learning teams are more likely to succeed. Learning knowledge is a personal process, and when a student has the opportunity to build his/her own knowledge system, she/he can enjoy the learning process [10][11]. However, the POGIL model also has some shortcomings, such as incomprehensiveness, polarization of student performance, limited time for class and discussion, and student non-familiarity with the inquiry learning model.
To avoid disadvantages and further optimize the POGIL method, we used the POGIL-based ipped classroom model for teaching emergency medicine to improve teaching effectiveness. This study found that the POGIL-based ipped classroom model improved students' achievements in learning emergency medicine, improved students' interest in learning emergency medicine, and enhanced students' team collaboration and clinical thinking skills; therefore, this new teaching model was found acceptable by most students. There were no signi cant differences in the content taught between two groups. In the teaching model combining both POGIL and a ipped classroom, heuristic teaching was carried out for students based on case studies of various clinical diseases in emergency medicine, in order to fully mobilize students' subjective initiative and learning enthusiasm, increase students' team communication and collaboration skills, and improve students' rst aid awareness and clinical skills.

Limitations
There are two limitations to this study. One is that the study is a single center study, so its results may not be generalizable to students in other colleges. Another limitation is that we assessed only the short-term results of the combined method. Therefore, further studies are required to investigate whether the bene ts of this combined method extend to the long term as well.

Conclusions
In short, the POGIL-based ipped classroom model was applied to emergency medicine teaching and signi cantly improved student achievement and increased students' enthusiasm toward learning, indicating that it is an effective teaching model. However, this teaching model is still being developed and requires investigations and improvements by teachers and scienti c researchers to ensure effective training of medical students.