Key words didactics - heutagogy - interactive learning environments - key feature questions
- flipped classroom - medical education
Introduction
Over the past centuries, the main lecture series has been a cornerstone in German
university education. The didactic lecture represents an integral part of the medical
curriculum and is used for comprehensive factual knowledge transfer in each subspecialty.
As a matter of fact, the traditional lecture format is still the dominant method of
instruction in higher medical education, even though, it is a largely passive experience
for many students. The possibility for students to interact with their lecturers is
limited. The traditional lecture is characterized by passive learning, students receive
information but do not otherwise engage with the learning content [1 ]. According to the revised cognitive Bloom’s taxonomy of Anderson and Krathwohl,
the traditional lecture can be classified hierarchically in a lower cognitive domain
of “remembering” and “understanding” ([Fig. 1 ]) [2 ]
[3 ]. Thus, a higher level of competence such as “applying” and “analyzing” remains unattainable
with the lecture methodology since its main purpose is the transfer of factual knowledge.
The only active task students undertake during a lecture is to take notes. Nevertheless,
in radiology the didactic concept of traditional lecture series is characterized by
motivated lecturers to demonstrate the latest imaging technologies with the endeavor
to give students a comprehensive overview of state-of-the-art radiological imaging.
Surprisingly, a review of the last decade showed that only an average of one fifth
of students were regularly attending the compulsory lecture series in radiology and
nuclear medicine. In fact, for exam preparation, students use online scripts and copies
of lecture slides, and thus skip the actual lecture.
Fig. 1 Bloom’s Taxonomy for educational objectives (adapted from Bloom, 1956 [1 ]; Anderson & Krathwohl, 2001 [2 ]) demonstrating the level of competence with corresponding options of examination
methodologies. MCQ = multiple choice question; OSCE = objective structured clinical
examination.Abb. 1 Blooms Taxonomie der Lernziele (nach Bloom 1956 [1 ] und Anderson & Krathwohl, 2001 [2 ]). Gezeigt werden die Ebenen der Kompetenzen mit ihren korrespondierenden Messmethoden.
MCQ = Multiple-choice-Fragen; OSCE = objective structured clinical examination.
We as lecturers felt that the traditional lecture concept needed to be improved to
make learning more attractive and to facilitate a higher level of competence. With
the introduction of the blended learning (BL) concept referred to as the “flipped
classroom”, combining multimedia-based and cooperative elements, we intended to promote
a heutagogical didactic approach. Heutagogy refers to a self-determined learning concept
that promotes autonomy, capacity, and capability of students [4 ]
[5 ].
In this study, we aimed to investigate whether a “flipped classroom” radiology lecture
leads to markedly improved acceptance and subjective learning progress in medical
students and whether medical teachers endorse the new lecture concept with regard
to efforts and benefits as compared to the traditional lecture.
Materials and Methods
Study Design
A non-randomized prospective observational study was conducted to evaluate the introduction
of an innovative BL concept referred to as the “flipped classroom” for radiology lectures
to increase cooperative learning. The novel BL concept was compared to a historical
control group of traditional lectures from previous years. Our project represents
a pilot test and evaluation of a complex educational setting that applies different
didactic elements conducted in a real-world setting. We hypothesized that student
satisfaction with the “flipped classroom” concept would be superior to the satisfaction
of a historical control group with traditional lectures.
Ethical approval for the evaluation protocol of this study was obtained from the local
ethics committee. All survey data from the study cohort and historical control was
analyzed anonymously.
Heutagogical, interactive “flipped classroom” lecture concept
The novel “flipped classroom” radiological lecture series was introduced for the first
time in the winter semester 2019/20 to a full cohort of fourth-year medical students
(n = 266). A completely new lecture concept was introduced. Beforehand, all students
were informed via online podcast about the heutagogical concept including the obligatory
preparation with learning videos and the new process in the lecture hall. Ten medical
teachers (hereinafter referred to as lecturers) participated in the 11 lectures. All
of them were board-certified radiologists, who had experience giving lectures and
had participated in the traditional lecture series in previous years. Each of the
nine radiologists and one nuclear medicine physician gave a lecture on their subspecialized
area of expertise.
The lecturers received training on the didactic concept regarding how to define intended
learning outcomes (ILO), and how to prepare learning videos. They received a roadmap
to design the attending phase for their lecture. The lecturers conducted their lectures
with support of an assisting lecturer in the lecture hall. To define and translate
the ILOs to the students, it was important to identify their needs, attract their
interest, and meet their expectations regarding the lecture series [6 ]. ILOs were given to the students following the WIIFM principle (acronym: W hat’s i n i t f or m e?) looking through the eyes of students by using first-person perspective rather
than looking at the lecture content from the perspective of the teacher ([Fig. 2 ]) [7 ]. ILOs were forwarded with the learning videos and additionally communicated during
the interactive lecture in the lecture hall as well as on the worksheets.
Fig. 2 Structure of learning objectives following the “What’s in it for me” (WIIFM) principle
from the student perspective. Differentiating two cognitive levels of understanding
by learning videos and application/analysis by the interactive lecture with attendance
of the students in the lecture hall.Abb. 2 Struktur der Lernziele „What’s in it for me“ (WIIFM-Prinzip) aus Sicht des Studierenden.
Es werden die 2 kognitiven Ebenen des Verstehens mithilfe von Lernvideos und der Anwendung/Analyse
durch Teilnahme an interaktiven Vorlesungen dargestellt.
The “flipped classroom” can be considered as a special type of BL that reverses the
traditional learning environment in which a self-directed learning phase (online videos
for conceptual knowledge transfer) takes place before the classroom attending phase
(procedural knowledge transfer) to explore topics in greater depth, to impart skills,
and to create meaningful learning opportunities [8 ]. The flipped classroom concept is best described by heutagogical learning, otherwise
known as self-determined learning. In a heutagogical approach of teaching and learning,
learners are highly autonomous and self-determined. Emphasis is placed on the development
of learner capacity and capability with the goal of producing learners who are well-prepared
for the complexities of today’s workplace [9 ].
The “flipped classroom” concept was applied as an active learning model, in which
students first learn content at home by video lectures (preparation phase), and thereafter
discuss and solve problems within the class (attendance phase) [10 ]. The participating lecturers were asked to prepare a short online learning video
on their specific lecture topic. The specification of an ideal length for the video
lesson was eight to twelve minutes [11 ]. The videos focused only on one component of the lecture topic (radiology subspecialty)
with the specific intention of preparing the students for the interactive attendance
phase in the lecture hall. Students were asked to watch the online learning videos
and prepare themselves with additional resources. A timeframe of at least 45 minutes
was recommended for preparation.
Instead of using the attendance phase for factual knowledge transfer, it was transformed
into an interactive and collaborative learning experience. A so-called sandwich design
was integrated to recall learned knowledge and to increase the students’ attention
span during the lecture [12 ]. The sandwich design contains different alternating didactic methods which reinforced
themselves ([Fig. 3 ]). In the attendance phase, key-feature questions (KFQs) represented the backbone
of the sandwich design. The KFQs were written on worksheets which were handed out
to the students at the beginning of the lecture. A short case description (eyecatcher
function) represented the entry point.
Fig. 3 Sandwich design of the interactive lecture (attendance phase) in the lecture hall.Abb. 3 Sandwich-Prinzip der interaktiven Vorlesung (Teilnehmerphase).
Each lecture contained one specific case description followed by 3 to 5 key features
which had to be solved in buzz groups by the students during the lecture. The use
of buzz groups represents a main procedure step of the interactive lecture concept
to encourage cooperative learning with active participation of individual students
during the lecture [13 ]. Buzz groups were formed by dividing the large group of students in the lecture
hall into small discussion groups of 2 to 3 students who meet simultaneously for a
specified time to discuss a specific question (collaborative phase) [14 ]. Buzz groups were formed by students who were sitting next to each other in a row
of the lecture hall. Each buzz group received a worksheet and a televoting “clicker”
for the audience response system (ARS; synonym for TED = Technology, Entertainment,
Design) (Turning Technologies, Youngstown, Ohio, USA). The individual votes of the
KFQs of each buzz group were entered into an online clicker. The anonymized analyses
of all votes were displayed immediately on the screen of the lecture hall [15 ]. The results of the buzz group votes on each KFQ were discussed interactively between
students and the lecturer (interactive phase). According to the sandwich design, this
alternation between cooperative and interactive phases was repeated until all KFQs
had been answered and discussed. As the exit point of the interactive lecture after
solving the KFQs, a transfer to the diagnosis and treatment options was summarized
by the lecturer at the end of the interactive lecture.
In contrast, traditional radiology lectures had been given from the front of the lecture
hall using PowerPoint presentations with printed versions of slides that were accessible
online for exam preparation. Knowledge and understanding of state-of-the-art technologies
had been imparted mainly by means of clinical cases. Lecturers for the historical
control group were largely the same as for the study cohort. Lecture topics were the
same as in the novel “flipped classroom” concept. However, no ILOs were defined. Except
for an obligatory 90-minute seminar concerning general radiology, dialog between the
lecturer and students as well as a professional exchange among students was rare in
the historical control.
Surveys and outcomes
The study cohort participated in the interactive “flipped classroom” lecture series,
whereas the historical control group underwent previous years of traditional lecture
series representing the classic lecture style ([Fig. 4 ]). Both study groups with all participating fourth-year medical students had to undergo
a multiple-choice (MC) examination at the end of the lecture series. Students were
asked to voluntarily complete a quantitative paper questionnaire with a 6-point rating
scale (with 1 representing the highest, and 6 the lowest level of satisfaction) of
seven questions on specific quality and process issues. This questionnaire also offered
a section for free-response "further comments" after the radiology exam. The end-of-semester
exam as well as the questions on the students’ survey remained identical to the previous
years to allow a direct comparison of students’ achieved grades, given evaluations,
and reported experiences.
Fig. 4 Evaluation flowchart. KFQ = key feature question.Abb. 4 Flussdiagramm der Evaluation. KFQ = key feature question.
An additional voluntary student assessment was offered to the study cohort following
each BL “flipped classroom” lecture. Specifically, students were asked to assess learning
videos, ARS, interactive exercises, and buzz group activities. The survey consisted
of a 3-point bipolar Likert scale (agree, neutral, disagree) for four questions immediately
after each of the 11 topics of the lecture series. Moreover, students were asked to
report their overall impression of each lecture topic on a 0–10 rating scale (0 = not
satisfied, 10 = extremely satisfied) immediately after the lecture.
Apart from this, after the end of the semester, a survey of the medical teachers was
conducted by means of a focus group interview to evaluate their perception of the
interactive “flipped classroom” concept. All lecturers were invited to participate
in a moderated group discussion to report on their experience with the new lecture
format [16 ]. According to an interview manual, seven questions were asked. In detail, the questions
related to the general impression of “flipped classroom” lectures, the main impact
of the concept, effort needed, ARS, buzz groups, change compared with traditional
lectures, and student satisfaction. These questions were outlined on a pinboard by
the moderator. Applying a metaplan technique, lecturers were asked to write down their
valuations and ideas on cards and to pin them to the board. In the further evaluation
process, the lecturers’ cards were sorted and summarized in an affinity diagram [17 ].
Statistics
Categorical variables are given as counts and percentages and continuous variables
as means and standard deviations (SD). Differences were assessed with Mann-Whitney
U or chi-squared tests. Results are presented as parameter estimates and their corresponding
95 % confidence intervals (CI). A two-sided value of p < 0.05 was considered statistically
significant. Analysis was performed using XLSTAT (Version 2015.6.01.24 026, Addinsoft,
Paris, France).
Results
In the voluntary end-of-semester student survey, 254 ± 4.7 students of the “flipped
classroom” lecture (winter semester 2019/20) and 77 ± 0.9 students of the previous
years’ traditional lecture (winter semesters 2017–2019) answered the standardized
questionnaire. The survey response rate of the “flipped classroom” lecture group was
95.6 % as compared to 28.8 % in the traditional lecture group. The overall impression
was rated with an average school grade of 1.5 (good) in the “flipped classroom group”
and with 2.7 (satisfactory) in the traditional lecture group (p < 0.001). The detailed
survey results are shown in [Fig. 5a ]. The students’ examination grades were slightly but significantly better (1.8 [95 %
CI: 1.7–1.9]) in the “flipped classroom” group as compared to the traditional lecture
group (2.0 [95 % CI: 1.9–2.0]; p < 0.001) ([Fig. 5b ]). A summary of the students’ survey results regarding their learning experience
with the interactive lecture is shown in [Table 1 ].
Fig. 5 a Results of the student survey regarding the lecture series following the blended
learning “flipped classroom” concept or the traditional concept of teaching immediately
after exam and b students’ examination grade. Continuous vertical lines indicate overall impression
of the respective radiology lecture series.Abb. 5 a Ergebnisse der Studierendenbefragung zur Vorlesungsreihe klinische Radiologie nach
dem Konzept des integrierten Lernens „flipped classroom“ oder dem der traditionellen
Vorlesung unmittelbar nach dem Examen. b Examensnoten. Durchgehende vertikale Linien zeigen den Gesamteindruck der Studierenden
von der jeweiligen Lehrmethode.
Table 1
Results of a survey of medical students regarding the “flipped classroom” blended
learning concept after the radiology exam.Tab. 1 Ergebnisse einer Befragung der Studierenden zum Konzept des integrierten Lernens
„flipped classroom“ nach dem Examen.
positive aspects
negative aspects
suggestions for improvement
The students’ assessment of the different topics of the lecture series demonstrated
that students broadly agreed that learning videos were helpful for preparation of
the individual lecture topics in 8 out of 11 videos. Students were dissatisfied with
the learning videos only for gynecological radiology, prostate MRI, and pediatric
radiology. For all lecture topics, students agreed that the ARS was a useful learning
tool, that they gained additional insight through the interactive lecture experience,
and that the buzz groups were helpful for them ([Fig. 6 ]).
Fig. 6 Students’ assessment of every lecture following the blended learning “flipped classroom”
concept on a 3-point bipolar Likert scale immediately after the lecture. ARS = audience
response system.Abb. 6 Studentische Beurteilung unmittelbar im Anschluss an die Vorlesung nach dem Konzept
„flipped classroom“ auf einer 3-stufigen bipolaren Likert-Skala. ARS = Abstimmungssystem.
Students reported an individual overall impression of the lecture series which was
extremely or very satisfied for 8 out of 11 topics. Even with the remaining 3 topics
(gynecological imaging, prostate MRI, and pediatric radiology), students were still
satisfied ([Fig. 7 ]). A comparison of surveys demonstrated a significantly better overall impression
of the lecture series after the examination at the end of the semester as compared
to a summary of the individual surveys right after each lecture with respect to learning
videos, additional insights, and buzz group experience (p < 0.01). The overall usefulness
of the ARS was rated equivalent after the lecture and the examination at the end of
the semester ([Fig. 8 ]).
Fig. 7 Student-reported overall impression of the lecture series following the blended learning
“flipped classroom” concept on a rating scale of 0 to 10 (0 = not satisfied, 10 = extremely
satisfied) immediately after the lecture. Box plots indicate median and interquartile
range. Whiskers end with the lowest and highest data point within 1.5 × interquartile
range. Dots represent means with their corresponding 95 % confidence interval. Crosses
indicate the proportion of students who did not watch the learning video.Abb. 7 Gesamteindruck der Studierenden von der Vorlesungsreihe nach dem Konzept des integrierten
Lernens „flipped classroom“ unmittelbar nach der Vorlesung auf einer Skala von 0 bis
10 (0 = nicht zufrieden, 10 = sehr zufrieden). Box-Plots zeigen Median und Interquartilsabstand.
Die Enden der Whisker markieren die höchsten und niedrigsten Werte innerhalb des 1,5-fachen
Interquartilsabstands. Die Punkte zeigen die Mittelwerte mit ihren 95 %-Konfidenzintervallen.
Kreuze zeigen den Anteil der Studierenden, die das Lernvideo nicht angeschaut haben.
Fig. 8 Comparison of student-reported overall impression of the lecture series following
the blended learning “flipped classroom” concept on a 3-point Likert scale immediately
after the lecture and immediately after the exam. *P-value applies to the proportion
of students who agreed with the respective statement.Abb. 8 Vergleich der studentischen Einschätzung der Vorlesungsreihe Radiologie nach dem
Konzept „flipped classroom“ unmittelbar nach der Vorlesung und nach dem Examen auf
einer 3-stufigen Likert-Skala. *Die p-Werte beziehen sich auf den Vergleich der Anteile
derjenigen Studierenden, die der jeweiligen Aussage zugestimmt haben.
In the focus group interview, medical teachers endorsed the flat hierarchy. The role
of the medical teacher has changed from traditional lecturer as knowledge mediator
to moderator. They also stated that the interactive lecture meets students’ needs
and attracts their attention. However, the medical teachers complained that this new
interactive lecture concept required significant initial preparation effort. In addition,
there seems to be a lack of coverage of the entire radiology curriculum as compared
to the traditional lecture concept. The summarized focus group interview with the
lecturers is shown in [Table 2 ].
Table 2
Focus group interview with lecturers regarding the “flipped classroom” blended learning
concept after conclusion of the lecture series.Tab. 2 Fokusgruppen-Interview mit den Dozierenden zum Konzept des integrierten Lernens
„flipped classroom“ nach Abschluss der Vorlesungsreihe.
questions
positive aspects
negative aspects
please give your general impression of the “flipped classroom” concept.
what was the main impact of the “flipped classroom” concept?
stepwise acquisition of knowledge
matches clinical issues
practical application of selected skills
attracts students’ attention
encourages independent planning and structured approach
how much effort was needed for preparation and implementation?
how do you assess key feature questionnaire by audience response system (ARS)?
how would you assess students’ group work and buzz groups?
how would you assess students’ group work and buzz groups?
what has changed regarding your role as a lecturer?
how do you assess spatial conditions?
from knowledge mediator to moderator
increased interaction with students
“integrated” teacher
flat hierarchy
can be realized with up to 200 students
do you think the students were satisfied and learned more than with traditional lectures?
(effect on attendance?)
Discussion
The heutagogical BL concept of teaching was implemented and tested under real-world
conditions with a full cohort of fourth-year medical students applying a design-based
research approach [18 ]
[19 ]
[20 ]
[21 ]. The central goal was to enable interactive and cooperative learning in the lecture
room. Chi et al. proposed an engagement behavior of students that outlines four levels
of activity, predicting that as students become more engaged with the learning content,
from passive to active to constructive to interactive, the learning effect will increase
(ICAP framework) [22 ]. The advantage of our approach is that we go far beyond the factual knowledge transfer
of a traditional lecture because an interactive lecture concept enables a learning
experience in a higher cognitive domain. The students perform lower levels of cognitive
work (gaining knowledge and comprehension) outside the class (learning videos) and
focus on the higher levels of cognitive work (application, analysis, synthesis, and
evaluation) in class during the lecture (attendance phase), where they have the support
of their peers and lecturers.
The students are guided interactively to discuss KFQs in small buzz groups. Each buzz
group needs to agree on exactly one answer, meaning that there must be a phase of
knowledge activation and discussion before an agreed-upon common response was entered
on the clicker. This process strongly supports interaction of students in the large
lecture hall by having them work cooperatively together in a predetermined time frame.
Following the sandwich design, these interactive phases in the buzz groups took place
repeatedly to solve the KFQs. The buzz group sets the groundwork to get the discussion
started. Buzz groups motivate and activate students to learn [23 ]. In combination with ARS, it also opens the door to new question types including
radiological images and text answers. Premkumar et al. have shown that ARS can support
active learning and meaningful rapid feedback to answers to KFQ responses. This is
certainly the main reason why the ARS was highly appreciated by the students and received
the highest grades of all voting items in the evaluation [24 ]. However, ARS itself does not improve learning. It just opens the door to the use
of didactic strategies that were previously not possible in a lecture hall with a
large number of students. Therefore, ARS can be considered an exciting addition to
the lecturer’s toolbox [15 ].
During the buzz group phase, the level of noise increased tremendously with about
50 buzz groups working in parallel cooperatively in the lecture hall. The lecturer
serves as moderator and is available for questions and for discussion of the KFQ results
after ARS votes. KFQs ought to test clinical decision-making skills. They are based
on the concept of critical steps or ‘key features’ in decision-making and represent
a reliable patient management problem format [25 ]. Fischer et al. have demonstrated that electronic KFQs can be applied as feasible
and reliable evaluation tools that may be implemented for the assessment of clinical
undergraduate training [26 ]. Conceptual knowledge is known to be an essential prerequisite for clinical problem
solving which has been conveyed by learning videos in the preparation phase, whereas
KFQs concentrate on procedural knowledge transfer to foster clinical experience and
clinical problem solving [27 ]. In the focus group interview, lecturers positively commented on how KFQs motivate
and increase students’ attention and thus prepare students for clinical activities.
BL combines traditional face-to-face learning and asynchronous or synchronous e-learning
[28 ], thereby providing the basis of our interactive lecture concept. The flipped classroom
intentionally shifts instruction to a heutagogical learner-centered model. Teacher
interaction with students is more personalized – with guidance instead of lecturing.
Bergmann et al. defined the flipped classroom concept as a framework that ensures
that students receive a personalized education, tailored to their individual needs
[29 ]. We introduced online learning videos to replace the conceptional knowledge transfer
which was done before in a traditional lecture as a place-based method.
Our study has some limitations. Evidence of comparative results is low because we
did not conduct a randomized comparison to traditional lectures. The historical control
consisted of students who attended one of the previous three winter semesters and
participation of these students in the survey was low. Furthermore, the students’
assessment of benefit from the lecture is highly subjective and might not reflect
gained skills and sustainability with certainty. Even exam grades do not necessarily
predict subsequent professional skills. Finally, student satisfaction might have been
associated with the lecturers’ increased motivation in “flipped classroom” lectures
due to their greater involvement in didactic preparation.
Conclusion
We implemented and evaluated the heutagogical, multimedia-based “flipped classroom”
learning concept in radiology lectures for fourth-year medical students to promote
self-determined and cooperative competencies. The students’ overall impression of
the “flipped classroom” concept including the categories of content, clarity, didactic
quality, lecturers’ involvement, and gain of knowledge was superior to that of traditional
lectures as rated by a historical control group. Lecturers noted a better match of
achieved competencies with later professional requirements.
Implementation of the “flipped classroom” concept involves considerable effort on
the part of lecturers.
Clinical relevance of the study
The “flipped classroom” model following the concept of blended learning supported
greater student activity compared to traditional lectures.
Heutagogical teaching conveys higher levels of competence such as interpretation of
radiological images, diagnosis, and communication of radiological findings.
Promotion of self-determined, cooperative student learning improves subsequently required
professional skills in clinical radiology.
