Setting and Participants
We invited 74 final-year undergraduate interns to participate this study. All participants were scheduled to rotate in our affiliated hospital in academic year 2019–2020 and the progress of their internship was basically consistent. In the period of this study, they were suspended clinical practice and stayed at home because of the COVID-19 outbreak and pandemic.
This was a prospective, controlled educational research study. Using the random number table, participants were divided into a flipped classroom or standard classroom with 37 participants in each classroom group. Figure 1 displays our research design and interventions.
Both flipped classroom and standard classroom utilized the Network Teaching Platform built and provided by Shanghai University of Medicine and Health Sciences to carry out the instruction. Educational content of our COVID-19 curriculum was from "Program of Diagnosis and Treatment of COVID-19 (trial 7th edition)" issued by National Health Committee of the People’s Republic of China . The total lecture period was set up as 120 minutes long in each group. A teaching team consisted of 3 clinical teachers was responsible for both formats of 120-minute live online COVID-19 curriculum. To maintain consistency between the two groups, one teacher prepared all teaching materials and gave demonstration lectures for both formats. The other two teachers held the live online curriculum respectively at the same time during the intervention protocol. Materials were peer-reviewed by all teachers before live online instruction. The demonstration lecture using traditional teaching was recorded and decomposed into micro-lesson videos. A total of 12 videos were developed, each of which focused on one or two learning points and controlled within 10 minutes.
The standard classroom group utilized traditional lecture, while the flipped classroom group applied micro-learning combined with CBL. The standard classroom group’s live online instruction consisted of 115-minute lecture given by clinical teacher on COVID-19 utilizing PowerPoint (PPT) slides, followed by 5 minutes for intern questions. The flipped classroom group’s live online instruction consisted of 120-minute discussion on typical clinical cases of COVID-19 guided by the teacher including in-class interactive questions responded by interns.
One week before the live online COVID-19 curriculum, we uploaded lecture PPT slides or micro-lesson videos respectively for participants in standard classroom group or those in flipped classroom group to preview or self-study. A knowledge pretest was administered before classroom division, a knowledge posttest immediately at the conclusion of their online COVID-19 curriculum, a questionnaire following the posttest, and a retention test 2 months later. Pretest, posttest, retention test and questionnaire were delivered at the same time in the two groups on the Network Teaching Platform.
We collected the demographic characteristics of interns when the participants were invited. A 25-item multiple-choice knowledge test on five dimensions of COVID-19 consisted of clinical manifestations, etiological detection methods, serological detection antibody titer characteristics, diagnostic criteria, and clinical typing was developed to measure the knowledge benchmark (pretest), acquisition (posttest) and knowledge retention (retention test). The total score of the knowledge test was set as 100 and composed of five dimensions with 20 per dimension. For clarity, length, and difficulty, we piloted the knowledge test on PGY-1 residents and faculty in primary care, respiratory, and infectious disease who did not participate in the study. The same test with varied question order was utilized for maintaining consistency among pretest, posttest and retention test. A questionnaire utilized Yes or No form including willingness to learn the knowledge of infectious diseases, practice hand hygiene, practice wearing self-protection, and return to internship rotation was developed to assess participants’ attitudes toward clinical practice.
Outcomes and Analysis
We compared mean scores in pretest, posttest and retention test between flipped classroom group and standard classroom group using independent-samples t test. We performed paired samples t-test for each dimension knowledge and overall outcome, comparing the change in scores from pretest to posttest, and from posttest to retention test in the same group. A χ2 test was used to compare attitudes toward clinical practice between the two groups.
Ethics and consent
This study was deemed exempt by the Institutional Review Board of Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital. The need for individual participant consent was waived.