UCSD Self Directed Essay

Please read through these instructions carefully before beginning. The CCPA Program is designed to provide guided self-directed material to the students to complete prior to coming to class. Students receive various pre-class learning materials and will review the materials on their own prior to in-class activities which are done individually as well as in small-groups. When students meet in class, they join their small group and work through guided materials and cases, and often have post-class assignments. The below activity is a simple example of this learning style. Please review the journal articles and complete the activity.

PRE-CLASS MATERIAL:

BRIEF REPORT
Flipped Classrooms in Physician Assistant Education
Bathri N. Vajravelu, PhD, MBBS, MPH; Alicia Kelley, MS, PA-C; Afsoon Moktar, PhD, EMBA;
Scott Orrahood, MPAS, EM, PA-C
Purpose This study assessed the impact of flipped classrooms on physician assistant (PA) students’ performance
and opinions.
Methods Students completed quizzes and an opinion
survey in Genetics, Human Pathophysiology (HPP), Clinical
Medicine (CM) (n = 105) and Physical Exam (PE) (n = 98)
courses.
6 8.82) compared to the flipped classrooms (75.12 6 8.54).
In CM, students’ gain score was significantly higher for
flipped classrooms (37.85 6 16.73) than for traditional
lectures (20.97 6 15.55). The opinion surveys showed that
the students surveyed preferred traditional lectures over
flipped classrooms in Genetics (4.58 6 0.46 vs. 2.29 6 0.71)
and HPP (4.14 6 0.35 vs. 2.09 6 0.53).
Results In Genetics and PE, the quiz scores were significantly higher for flipped classrooms (Genetics 95.00 6 6.56;
PE 83.09 6 11.47) compared to the traditional lectures
(Genetics 90.00 6 10.53; PE 55.43 6 16.66). In HPP,
students performed better with traditional lectures (86.54
Conclusion Flipped classrooms improved the quality of
learning in courses that deliver a hands-on skill or use casebased scenarios. They may not be an ideal choice for
courses that require explanation of intricate scientific
concepts.
INTRODUCTION
incorporated found the results to be overwhelmingly positive.
Similar studies are needed in PA education to bridge the
knowledge gap that exists regarding the utility of this approach.
This study investigated the performance outcomes as well
as opinions of PA students regarding flipped classrooms. The
results of this study can expand our understanding of the
effectiveness of the flipped classroom model in PA education
and guide the development of an effective PA curriculum.
The purpose of the flipped classroom as a pedagogical
method is to create more active learning opportunities as well
as more efficient student-teacher interactions.1 This approach
is particularly relevant in the current environment of predominantly online and hybrid teaching models given the
coronavirus disease 2019 (COVID-19) pandemic. The concept
of the flipped classroom was pioneered in large part by Jonathan Bergmann and Aaron Sams in 2007.2 In the original flipped
classroom approach, direct instruction (such as lecture) was
delivered via videos that the students watched at home prior to
the in-class activity,2 which is where active learning opportunities took place. In the classroom, the students would do what
traditionally would have been homework, hence the term
“flipped.” The flipped classroom approach has become
increasingly popular in a variety of health education settings.
This includes curricula involving medical students, medical
residents, nurses, dental, and pharmacy disciplines.3 Yet, there
is scant evidence on the utility of the flipped classroom in
physician assistant (PA) education.
A large meta-analysis published in 2014 in the Proceedings
of the National Academy of Sciences demonstrated significant
improvement in performance in active learning environments
in the fields of science, technology, engineering, and math.4
The results of another meta-analysis revealed that active
learning, which is considered to be the quintessential outcome, leads to application of knowledge in a variety of clinical
settings.5 A study by Critz and Knight6 that surveyed graduate
nursing students after a flipped classroom approach was
The authors declare no conflict of interest.
J Physician Assist Educ 2020;31(4):207–211
Copyright ª 2020 Physician Assistant Education Association
DOI 10.1097/JPA.0000000000000325
METHODS
The results are a combination of 2 studies conducted in the fall
semester of 2015 and 2016. In fall 2015, the study participants
were the Class of (CO) 2017 enrolled in the Physical Exam (PE)
course (n = 98) and the CO 2018 enrolled in the Human
Pathophysiology (HPP) and Genetics courses (n = 105). In fall
2016, the participants were the CO 2018 (n = 105) enrolled in
the Clinical Medicine (CM) course. Each of these courses were
delivered by individual instructors, with the same instructor
delivering and testing all the flipped classrooms and traditional lectures within a course. The studies were approved as
exempt by the institutional review board at the Massachusetts
College of Pharmacy and Health Sciences University.
A detailed description of the study methods, including the
types of flipped classroom implemented, as well as the topics,
sample tests, and survey questions, is provided in the supplemental material (see Supplemental Digital Content 1 and
2, http://links.lww.com/PAEA/A9 and http://links.lww.com/
PAEA/A10). During the first class meeting, the principal
investigator briefly explained the study, read the elements of
the consent form to the students, and encouraged their participation on a voluntary basis. All of the students who enrolled
in the courses attended classes that were taught in both the
traditional and flipped classroom formats for selected topics.
For the flipped classrooms and traditional lectures, students
December 2020  Volume 31  Number 4
Copyright © 2020 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited.
207
BRIEF REPORT
Table 1. Response Rates for Quizzes and Opinion
Survey
Assessment
HPP
(n = 105)
Genetics
(n = 105)
PE
(n = 98)
CM
(n = 105)
Quizzes
102 (97%)
102 (97%)
75 (76%)
25 (24%)
Opinion
survey
35 (33%)
37 (35%)
14 (14%)
26 (25%)
CM, Clinical Medicine; HPP, Human Pathophysiology; PE, Physical Exam.
completed an online quiz before the class meeting to test their
baseline knowledge about the subject matter (pretest). Classes were then held in either the traditional or flipped classroom format using one of the methods as explained in the
supplemental material (see Supplemental Digital Content 1
and 2, http://links.lww.com/PAEA/A9 and http://links.lww.
com/PAEA/A10). At the end of each flipped classroom and
traditional lecture, students were then asked to complete
another online quiz (posttest). In fall 2015, the pretest was not
given for the PE, HPP and Genetics courses; therefore, only the
postlecture test scores for the traditional lectures and flipped
classrooms were compared. At the end of the semester, stu-
dents were encouraged to complete an online opinion survey
about their experience with the different lecture formats.
SPSS statistical software package version 26 (IBM: Armonk,
NY) was used to analyze the data. Data are presented as mean
6 standard deviation. Descriptive analysis was performed
using mean, frequencies, percentages, and other measures of
central tendency. The distribution of differences was normal
for all except the Genetics and PE quiz scores, as assessed by
the Shapiro-Wilk test. Because the paired-samples t-test is
robust to violations of normality,7 it was used to compare the
differences between the mean scores. P < .05 was considered to be statistically significant. RESULTS The response rates for the quizzes and opinion survey are shown in Table 1. Quiz Scores Two flipped classrooms and 2 traditional lectures were compared in Genetics and PE courses, and 3 flipped classrooms and 3 traditional lectures in HPP and CM. Results on the quiz performances were mixed between courses. In the Genetics Figure 1. Quiz scores for the Genetics (A), Physical Exam (B), and Human Physiology and Pathophysiology (C) quizzes were compared. The numbers (1, 2, 3) indicate individual lectures. 208 Journal of Physician Assistant Education Copyright © 2020 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited. BRIEF REPORT Figure 2. A, The pre- and posttest scores for the 3 Clinical Medicine (CM) traditional lectures were compared. B, The pre- and posttest scores for the 3 CM flipped lectures were compared. C, The change in mean score from the pre- and posttest scores was tested for statistical significance. The numbers (1, 2, 3) indicate individual lectures. and PE courses (Figure 1A, B), the overall mean score on the postlecture quizzes for the flipped classrooms was significantly higher (Genetics 95.00 6 6.56; PE 83.09 6 11.47) compared to the traditional lectures (Genetics 90.00 6 10.53; PE 55.43 6 16.66). In contrast, in the HPP course (Figure 1C), the students’ mean score on the postlecture quizzes was significantly higher for the traditional lectures (86.54 6 8.82) compared to the flipped classrooms (75.12 6 8.54). In CM, students’ baseline knowledge was measured using a prelecture online quiz (pretest) followed by the postlecture quiz (posttest). As shown in Figure 2A, B, both traditional lectures and flipped classrooms had a higher mean posttest score, and the difference between the pretest and posttest scores was statistically significant. To identify the model that resulted in a greater improvement, a gain score was calculated for both lecture formats. The flipped classrooms (37.85 6 16.73) had a higher gain score than the traditional lectures (20.97 6 15.55) and the difference was statistically significant (Figure 2C). Opinion Survey Similar to our results in the quiz performances, the students’ opinions on the flipped classroom model were bifurcated. As shown in Figure 3, the students preferred the traditional lectures compared to the flipped classrooms in both HPP (4.14 6 0.35 vs. 2.09 6 0.53) and Genetics (4.58 6 0.46 vs. 2.29 6 0.71) with a statistically significant difference. In PE, the mean scores were slightly higher for flipped classrooms (4.03 6 0.72) than for traditional lectures (3.77 6 0.83), although the statistical significance of this difference was not tested due to low response rate. In the CM course (Figure 4), 58% of the respondents felt that it was easier to pay attention in the flipped classroom, 62% felt they retained more of the material in the flipped classroom, and 42% were neutral. DISCUSSION In a traditional lecture, students passively listen to the instructor’s explanation of a topic, and most of the learning and retention takes place outside of the classroom. In contrast, in a flipped classroom, students listen to a prerecorded video or read an assigned article before the class and actively participate in peer-directed discussions during class time. There is a significant role for the flipped classroom model in the online and hybrid curricula that are being developed and modified due to the COVID-19 pandemic. December 2020  Volume 31  Number 4 Copyright © 2020 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited. 209 BRIEF REPORT Figure 3. Collective survey response analysis on the 2 lecturing formats. The significance of students’ desire for flipped Physical Exam (PE) lectures was not analyzed due to low response rate (14%). Evaluating students’ perceptions as well as their performances using pre- and postactivity quizzes, our study showed that while flipping the class can be effective in selected courses, students’ perceptions vary for different topics. Additionally, this study revealed that the flipped classroom enhanced students’ performances in CM, Genetics, and PE. These findings are similar to studies in other health professions that have demonstrated improved performances from students in a flipped classroom setting.6,9 The students’ performance and perception of the traditional lectures was also positive in some subjects. One explanation for this favorable perception in HPP is that the students continue using the undergraduate learning format, which is mainly delivered through face-to-face instructor-led lectures. Another explanation for a preference for traditional lectures is that short prerecorded videos might not be as comprehensive as traditional lectures, where the instructor can expand on difficult topics and is available to answer students’ questions in real time.5 The overall mean performance in Genetics was significantly higher in flipped classrooms, even though student satisfaction was significantly higher with traditional lectures. The fact that some students had previously taken an undergraduate genetics course likely contributed to their ability to better comprehend and retain knowledge. In the PE course, the students had more positive perceptions as well as superior performance in flipped classrooms over traditional lectures. Watching the PE videos improved students’ clinical skills and enhanced their performance in a team-based learning setting. These findings are in line with those of Giuliano et al and Cotta et al.8,9 The Penn State College of Medicine Physician Assistant 210 Program also has shown that team-based learning enhances the learning process.10 The positive student perception, as well as the superior performance in flipped classrooms, as contrasted with the traditional ones in CM, can be explained by greater opportunity for students to apply their knowledge of cardiovascular subject matter in an active learning environment. This approach fostered higher order reasoning such as analyzing and synthesizing knowledge. Furthermore, these findings are consistent with similar research in medical education.1 Some identifiable limitations of this study should be considered. First, pretest quizzes were not employed in HPP, Genetics, and PE courses to assess the students’ baseline knowledge of a given topic. It is possible that the level of difficulty between the 2 approaches influenced the performances, although the instructors for both standard and flipped classrooms were the same for any given course. Second, the number of students who participated in research in the CM course was low compared to HPP, Genetics, and PE. Various flipped classroom methods were used in this study including instructor-made videos, student-led PowerPoint presentations, and case studies. From the standpoint of evaluating the efficacy of different approaches, the use of diverse methods can be helpful. However, with that said, the lack of consistency regarding the flipped methods among the courses may have adversely impacted our ability to measure the effectiveness of the learning outcome. Finally, there were no long-term follow-ups to evaluate the students’ retention of the acquired knowledge. Figure 4. Opinion survey results for the Clinical Medicine course showed that, while PA students had positive comments about the flipped lectures, they found it difficult to find the extra time needed to watch the videos ahead of class and prepare for the case study discussion. Journal of Physician Assistant Education Copyright © 2020 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited. BRIEF REPORT CONCLUSION The data reported in this study indicate that the flipped classroom approach in PA education yields improvement in student learning and satisfaction compared to traditional teaching methods in clinical courses, such as CM and PE. The opportunity for active learning, critical thinking, and the application of the knowledge are deemed to be the contributing factors. The findings of this study can serve as the first step for future research focusing mainly on improving study methods and research design. This paradigm shift in teaching methodology may require the development of longitudinal studies to investigate whether the long-term learning retention can be superior in the flipped classrooms compared to that of the traditional lecture method. Bathri N. Vajravelu, PhD, MBBS, MPH, is an assistant professor of Physician Assistant Studies at MCPHS University in Boston, Massachusetts. Alicia Kelley, MS, PA-C, is an assistant professor of Physician Assistant Studies at MCPHS University in Boston, Massachusetts. Afsoon Moktar, PhD, EMBA, is an associate professor of Physician Assistant Studies at MCPHS University in Boston, Massachusetts. Scott Orrahood, MPAS, EM, PA-C, is an associate professor of Physician Assistant Studies at MCPHS University in Boston, Massachusetts. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://www.jpae.org). Correspondence should be addressed to: Bathri N. Vajravelu, PhD, MBBS, MPH, Department of Physician Assistant Studies, MCPHS University, 179 Longwood Avenue, Boston, MA 02115. Telephone: 617-732-2961; Email: bathri.vajravelu@mcphs.edu REFERENCES 1. Chen F, Lui AM, Martinelli SM. A systematic review of the effectiveness of flipped classrooms in medical education. Med Educ. 2017;51(6):585-597. 2. Bergmann J, Sams A. Flip Your Classroom: Reach Every Student in Every Class Every Day. Eugene, OR; Alexandria, VA: International Society for Technology in Education; 2012. 3. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ. 2018;18(1):38. 4. Freeman S, Eddy SL, McDonough M, et al. Active learning increases student performance in science, engineering, and mathematics. Proc Natl Acad Sci USA. 2014;111(23):8410-8415. 5. Chen KS, Monrouxe L, Lu YH, et al. Academic outcomes of flipped classroom learning: a meta-analysis. Med Educ. 2018;52(9):910-924. 6. Critz CM, Knight D. Using the flipped classroom in graduate nursing education. Nurse Educ. 2013;38(5):210-213. 7. Rasch D, Guiard V. The robustness of parametric statistical methods. Psych Sci. 2004;46(2):175-208. 8. Giuliano CA, Moser LR. Evaluation of a flipped drug literature evaluation course. Am J Pharm Educ. 2016;80(4):66. 9. Cotta KI, Shah S, Almgren MM, Macıas-Moriarity LZ, Mody V. Effectiveness of flipped classroom instructional model in teaching pharmaceutical calculations. Currents Pharm Teach Learn. 2016;8(5):646-653. 10. Penn State University. Team-based Learning Sets College of Medicine Physician Assistant Program Apart. https://news.psu.edu/story/467972/ 2017/05/11/team-based-learning-sets-college-medicine-physician-assistantprogram-apart. Published May 11, 2017. Accessed September 8, 2019. December 2020  Volume 31  Number 4 Copyright © 2020 Physician Assistant Education Association. Unauthorized reproduction of this article is prohibited. 211