Traditionally, medical education has been focused on how to teach facts and knowledge for students to learn; therefore, one-way, lecturer-centered education was considered the best way to learn. However, over past decades, there have been many changes in medical education, and various methods of education have been tried, focusing on what educational experiences and interactions among students can achieve for their learning outcomes.10 This educational trend has also emerged in the medicine-related fields, resulting in strategies for active learning, such as Problem-Based Learning (PBL).11 Active learning is learner-centered, where the individual’s needs are considered more essential than those of the group.12 In that regard, a learner needs to not only do something about given tasks but also reflect on what they are studying. Active learning supposes that all knowledge can be obtained individually by a learner, whereas passive learning assumes that knowledge can be transferred from one person (lecturer) to another one (learner).13 As an example of active learning, PBL reflects that knowledge is constructed rather than received, for it is based on the assumption that knowledge arises from work with an authentic problem. The adaptation of PBL has been very successful in the landscape of education for health professions; however, PBL has not been dominant as the collaborative learning method across or within institutions due to several limitations.14
As an alternative to PBL, Team-based learning (TBL) has gained recent popularity in medical education for health professions.15 In contrast to PBL, TBL does not require several tutors but maintains the advantages of small group teaching and learning. This advantage of TBL allows education related to health professions to provide learners with a resource effective and reliable environment in teams to solve clinical problems in the real world.16 In line with that reason, a previous study showed that students preferred TBL over PBL as the optimal teaching strategy in medical education.17 However, as with other teaching methods, TBL also has some limitations: initial time commitment from lecturers (e.g., readiness assurance tests and application exercises), strong willing to try a new teaching method to replace current strategies, and physical classroom space compared with traditional education. Thus, the demand for a novel paradigm beyond PBL and TBL applied to education for health professions has arisen.
To overcome constraints in the PBL and the TBL, a new education for health professions strategy may benefit from applying the ICAP. According to our results, participants performed better in the self-study condition than lecture condition and conditions across the types of items (Table 1):: total, rote, and transfer. The results suggest that rather than making learners unilaterally listen to lectures, it can be more effective to ask them to engage with learning materials by themselves in education programs for health professions. The implication of our result is consistent with a recently emerging educational concept, FL. In comparison with conventional learning, FL has distinctive features in a pedagogical approach that moves information-transmission teaching out of the classroom and uses class time for learning activities. As information technology advances, educational materials have become easily accessible, and not just limited to classrooms (e.g., massive open online courses, MOOCs). Students can be actively involved in constructing knowledge in their own way, regardless of place. In this regard, the role of classrooms and lecturers, which were the primary source of information, has been modified. By facilitating a lecturer, students gain a deep understanding of knowledge through activities such as concept exploration, meaning-making, experiential engagement, and demonstration/application during class time. In terms of FL, our experimental results based on the ICAP framework may present practical implications and theoretical support for new pedagogical approaches in education for health professions.
According to many studies, including the ICAP framework, the learning effect is larger when students participate in learning more actively. However, studies on how to maximize interaction are difficult to find. In this study, prior activity of discussion, lectures, and self-study were compared, and furthermore, the activities of simply receiving a given question and generating a question were considered. As a result, the SG group had the highest performance, and the LR group had the lowest performance when comparing the total score. For rote-memory type item scores, the self-SG and SR groups had higher performance ratings than the lecture groups (LG and LR). Finally, in the transfer type item scores, the SG group had the highest performance. Therefore, it can be considered that students who study by themselves and complete question-generated activities, students who participate in more active activities rather than simply listening to lectures and receiving given questions, and that students who complete passive activities experience increased learning outcomes.
In addition to self-study, question generation can be a useful strategy in actively constructing knowledge by learners. The SR group showed higher performance in the rote-memory item than the LG/LR group, but there was no significant difference in the transfer type items (Table 1).. Only the SR group showed higher scores in comparison to the LG/LR group in the transfer type items. These results suggest that not only summarizing what they have studied but also generating questions regarding the content can be effective in applying existing knowledge to other contexts. The students writing the questions for discussion themselves is more effective for learning than merely responding to given discussion questions.18 To build questions for the discussion, learners require an understanding of the given materials and then a process for “generating” new things based on understanding will accompany. Therefore, learners need a higher level of thought than they can receive through the activity of merely using given questions. Specifically, a discussion beginning with questions constructed by the learners can be more productive,19 affecting the enrichment of the class time through creating a high-level discussion. During the discussion, learners may experience the knowledge-change process from interactive activity, which is promoted by transfer learning through sufficient understanding regarding contents.
Further, among the two experimental treatments during study and discussion, only different study conditions showed significant results in the analysis of mental effort (Table 2).. Based on the results of the analysis of mental effort, we found that the degree of testing mental effort significantly correlates with students’ learning outcomes (Table 3),, i.e., the significant correlation between testing mental effort and post-test performance on transfer type items and results from the mediation analysis (Fig. 1) support the previous study.20 Overall, only the difference in mental effort patterns between two studying conditions and the simple mediation analysis combined suggest how students’ study affects the degree of mental effort during studying and testing, eventually influencing their learning performance. We agree with previous findings that support the elaborative retrieval theory, which suggests that mental investment explains why learners must invest substantial mental capacity.
Although, the discussion itself was not the focus of the current study, the results represented the conclusion that active self-study was associated with an involvement in discussion. The mental effort in the study session (M2) positively correlated with the mental effort in the discussion session (M3), suggesting that learners who actively engage in self-study would also actively engage in the course of the discussion (Table 3).. These results suggest that not only self-study before the class but also mental effort during self-study in terms of the ICAP framework or FL is an important element, which should be accompanied by active learning.
This study has some potential limitations. First, the video lecture used in the study, like traditional lecture forms, showed one professor unilaterally conveying knowledge. Moreover, most recent online lectures were conducted with the professor alone.21,22 However, in future research, the video might show a conversation and not the professor alone. Second, in this experiment, the discussion was among students with no interference from professors. However, past studies investigated that the enthusiasm of the instructor or professor may affect the students’ performance.23 Therefore, in the future, the method of activating discussion among students by minimizing the professor’s interference must also be actively reviewed.