The Flipped Classroom Approach to Improve Fundus Examination Skills for Medical Students: a Mixed-methods Study

Abstract BACKGROUND: Training for the fundus examination using traditional teaching is challenging, resulting in low generalist physicians’ confidence in performing the funduscopic exam. At the same time, there is growing evidence suggesting flipped classrooms’ value in teaching physical examination procedures. However, whether the flipped classroom is superior to the traditional, lecture-based teaching for the funduscopic exam and the cognitive processes supporting its effectiveness has not yet been determined. METHODS: We conducted a sequential explanatory mixed-method study to compare the flipped classroom approach’s effectiveness versus the traditional lecture-based classroom for teaching the funduscopic exam to the medical students at Chiba University in Japan. Medical students were randomly assigned to either a flipped classroom group or a traditional teaching group. We then quantitatively measured the diagnostic accuracy of funduscopic findings, the length of time to perform the fundus examination, and students’ confidence in performing funduscopic examinations, before and after attending the specific classrooms. Next, we conducted student focus groups to explore the students’ thinking processes in the flipped classroom and traditional teaching of fundus examination, respectively. The qualitative data were analyzed using the qualitative content analysis method.RESULTS: Diagnostic accuracy was significantly higher using the flipped classroom method (flipped: 36.6% to 63.4%, traditional: 28.3% to 34.6%, F (1,310) = 11.0, p = .001). The total examination time was significantly shorter using the flipped classroom teaching (flipped: 85.4s to 66.9s, traditional: 85.3s to 76.3s, F (1,310) = 14.7, p <.001). Six semi-structured focused group interviews were conducted (n=36). In the flipped classroom group, we identified 12 categories corresponding to five levels of the revised Bloom’s taxonomy: remember, understand, apply, analyze, evaluate. Five categories were identified in the traditional classroom group corresponding only to three levels of the revised Bloom’s taxonomy: understand, apply, analyze. Interrater reliability was substantial (Cohen’s kappa = 0.81). CONCLUSIONS: Teaching medical students funduscopic examination using the flipped classroom methodology leads to improved diagnostic accuracy, confidence, and motivation for funduscopic examinations, while reducing total examination time. The flipped classroom teaching method enabled higher levels of cognitive activity than the traditional, lecture-based classroom, as assessed using the revised Bloom’s taxonomy.