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Korean J Med Educ > Volume 36(2); 2024 > Article
Si: Exploring the responses of preclinical medical students and professors to flipped learning for the development of clinical reasoning

Abstract

Purpose

This study developed and implemented case-based flipped learning using illness script worksheets and investigated the responses of preclinical students and professors to the intervention in terms of its effectiveness, design, and implementation.

Methods

The study was conducted at a medical school in Korea, where the “clinical reasoning method” course, originally a lecture-oriented course, was redesigned into a flipped learning. In total, 42 second-year medical students and 15 professors participated in this course. After the class, online surveys were conducted, and a focus group interview was held with seven students to explore the students’ experiences in more detail.

Results

In total, 37 students and seven professors participated in the survey. The mean score for all items is 3.12/4 for the student survey and 3.43/4 for the professor survey. The focus group interview results were categorized as the beneficial aspects and challenges for the development of clinical reasoning.

Conclusion

The findings indicated that their responses to the intervention were generally positive, and it is thought to be an effective instructional method for fostering clinical reasoning skills in preclinical medical students.

Introduction

Developing clinical reasoning skills is one of the ultimate goals of medical schools. To develop clinical reasoning skills at all levels of medical students, curricula tailored to each stage of medical education are necessary. However, clinical reasoning training has often been confined to clinical clerkships, and the availability of the curriculum tailored to preclinical medical students remains limited [1].
It is widely acknowledged that cases-based learning is effective for the development of clinical reasoning skills [1,2]. However, dealing with real-life or authentic cases is often too complex and challenging for preclinical students with minimum clinical reasoning training. According to the cognitive load theory, if the intrinsic cognitive load is too high, imposed due to the inherent difficulty of a task, successful learning may not occur [3,4]. The cognitive load theory assumes that a human has a limited-capacity information processing system, and this limitation only applies to novel information [3]. To control the intrinsic cognitive load of novice learners in complex learning situations, the cognitive load theory suggests instructional strategies, including process worksheets, and collaborative learning [3]. Process worksheets illustrate a systematic approach to solving a task, which can alleviate task difficulty by providing procedural information. Additionally, collaborative learning potentially expands information processing capacity within a group. Consequently, intrinsic cognitive load can be distributed across group members, and sharing this load can alleviate their cognitive burden [3,4].
As an instructional method that incorporates authentic cases, process worksheets, and collaborative learning for preclinical students to develop their clinical reasoning skills, flipped learning is a viable option. Flipped learning requires students to engage in pre-learning activities before class and collaborative learning during the class with a focus on real-world tasks [5]. The process worksheets can be used to guide the clinical reasoning process during group discussions. While this intervention is deemed a suitable instructional method for clinical reasoning development in preclinical students, it has hardly been employed to develop clinical reasoning among preclinical students.
Therefore, as a preliminary study, this study aimed to develop and implement case-based flipped learning using process worksheets and investigate the responses of preclinical students and professors to the intervention in terms of its effectiveness, design, and implementation. The findings of this study offer valuable insights into effective flipped learning for fostering clinical reasoning skills in preclinical medical students.

Methods

1. Participants and procedure

This study was approved by the Institutional Review Board of Dong-A University (2-1040709-AB-N-01-202109-HR-070-04). This study was conducted at Dong-A University School of Medicine in Korea, where the “clinical reasoning method” course, originally a lecture-oriented course, was redesigned into a flipped learning and offered in the fourth quarter of the second-year medical program. The class was held once or twice per week, and 42 students worked in seven groups, with six students per group. The orientation for learners was conducted by a professor in the first class, and for the participating professors, the researcher conducted an orientation before the class, covering the overall structure of flipped learning, clinical case examples, worksheet examples, evaluation rubrics, and the role of the professor as a facilitator. Except for one professor who conducted the learner orientation, 14 professors participated in the flipped learning. Each professor created a clinical case (for example, edema, dizziness, dyspnea, and so forth) and developed their individual classes based on the guidelines and examples presented during the orientation session. Each professor conducted flipped learning once with their developed case and facilitated seven groups alone in one classroom.
Professor and student surveys were conducted online for 1 week after the class ended. One week after the survey, a focus group interview was also conducted with seven students to explore the students’ experiences in more detail. Three female and four male students voluntarily participated in the interview. The informed consent was obtained from all participants.

2. Flipped learning

Flipped learning was structured with activities before and during the class, as outlined in Table 1. Before the class, the professors were asked to develop a clinical case and the pre-learning materials. They were also asked to upload the pre-learning materials to the school’s learning management system a week before the class, and the students were asked to study them. The professors were also required to develop three online quizzes. During the class, they first presented them and checked the answers with the students. They then presented worksheets along with a clinical case and played a facilitator role during the group discussion. The students completed the worksheet through group discussions, and each group presented their completed worksheets in front of class. Internet searches were allowed during the discussion. The instructors provided feedback after the presentations, conducted a mini-lesson, and concluded with a question-and-answer session. After each class, they were required to write reflective journals. After the course, the students took a test designed to complete two illness script worksheets, each corresponding to a clinical case. Assessment of the reflective journal writing and test were performed using rubrics.

3. Illness script worksheet

The process worksheet utilized was adapted from the illness script worksheet developed by Levin et al. [6]. Clinicians possess a well-developed repertoire of illness scripts cultivated through learning and clinical experiences, and they make clinical decisions based on them in clinical situations [7]. These scripts are refined and elaborated based on their applications to clinical cases [7]. Therefore, novice learners start to develop their own illness scripts to enhance their ability to infer like experts. Consequently, illness script worksheets were employed in this study. They illustrate illness-script-based reasoning processes and were used to guide the group discussions. The worksheet includes a clinical case vignette, initial problem representation, three possible differential diagnoses, and an illness script table for each. It further includes comparing and contrasting the key features of the differential diagnoses and compiling a list of tests with their justification (Appendix 1). The illness script table incorporates enabling conditions, pathophysiological faults, and consequences (signs and symptoms), known as the components of illness scripts [6].

4. Student and professor surveys

Both surveys were adapted from previous research [6,8,9]. The student survey consisted of 14 items, including 10 items on a 4-point Likert scale (1: strongly disagree–4: strongly agree) (Table 2), two open-ended questions, and two demographic questions about age and gender. The professor survey focused on the design and implementation of flipped learning and consisted of 15 items, including 10 items on a 4-point Likert scale and five open-ended questions (Table 3). The focus group interview questions were about the beneficial aspects for the development of clinical reasoning and challenges encountered in the course (Appendix 2).

5. Data analysis

The collected data were analyzed utilizing IBM SPSS ver. 27.0 (IBM Corp., Armonk, USA). The survey items were assessed using Cronbach’s α and descriptive statistics. Data from the open-ended questions and the focus group interview were analyzed and categorized using content analysis by both the researcher and a research assistant. They independently reviewed and any discrepancies in their analyses were resolved through discussion.

Results

1. Participants’ characteristics

Among the 42 students enrolled in the course, 37 (88%) participated in the survey: 15 female students (40.5%) and 22 male students (59.5%). The age range was 23–27 years (mean: 24.35 years). In total, seven out of 15 professors (47%) responded to the survey. The reliability of the student survey was 0.90 (Cronbach’s α), and the professor survey was 0.87, both demonstrating a high level of internal consistency.

2. Survey results

The survey results are presented in Tables 2 and 3. For the student survey, the mean score for all items is 3.13. In response to the open-ended question about whether the course helped develop clinical reasoning skills, 25 students answered affirmatively, while others expressed challenges such as time constraints, task difficulty, and a lack of medical knowledge. Suggestions for improvement included the exam format, frequency of classes, time constraints, quantity of pre-learning materials, and quality of orientation. For the professor survey, the average score for all items is 3.43, and the results of the open-ended questions are presented in Table 3.

3. Focus group interview

The results of the focus group interview are presented in Appendix 2. The students indicated the beneficial aspects for the development of clinical reasoning as authentic clinical cases, collaborative learning, professors’ feedback, worksheet completion, reflective journal writing, and appropriate difficult level, and as challenges in the course, the quantity and upload timing of pre-learning materials, quality of orientation, too many learning activities, and time constraints.

Discussion

The study’s findings and corresponding design and implementation suggestions are as follows. Preclinical medical students generally expressed a positive view of the intervention. They indicated that the course was effective in developing clinical reasoning development and utilizing the illness script worksheet and authentic cases provided valuable learning experiences. These findings align with previous research [5,6,8,10] demonstrating the effectiveness of flipped learning or the illness script worksheet approach in terms of clinical reasoning development in preclinical students.
Furthermore, they expressed that collaborative learning was highly beneficial. As expected, working with group members was advantageous as they could share their cognitive burden with group members and simultaneously exposed them to diverse perspectives. These findings align with prior research suggesting that collaborative learning can be an effective way for novice learners in complex learning situations [3].
In addition, this study demonstrated that the intervention not only serves as an effective method for developing preclinical students’ clinical reasoning but also offers a more efficient approach to class delivery. Levin et al. [6] developed an illness script worksheet to guide preclinical students’ clinical reasoning process in small group settings, but in their study, students in groups of 15 completed the worksheet step-by-step with a facilitator. However, the implementation of the worksheet and collaborative learning in flipped learning enabled novice learners to collaboratively solve a complex problem with minimal facilitator assistance due to the reduced task difficulty. Consequently, one facilitator can efficiently oversee multiple groups in one classroom, allowing for multiple iterations of this intervention, unlike the one-time or short-term nature of previous studies [6,7].
The professors also revealed an overall positive teaching experience. Although they felt apprehension and were challenged, they thought they implemented it seamlessly, and the class was an effective method to develop the clinical reasoning skills of preclinical students. In addition, the findings indicated that the orientation session was particularly important for them to develop and deliver the course, and providing ample teaching assistance is recommended to reduce their burden, as flipped learning involves a subnational workload.
Both students and professors pointed out the time constraint as a significant drawback. Each class lasted 2 hours, but extending it beyond 2 hours per class seemed necessary to allow for a rich discussion and enough feedback from the professors. Additionally, there was a comment that twice a week was challenging. Given the course load, it is suggested that a once-a-week format would be more appropriate.
The students indicated the quantity and uploading timing of pre-learning materials, quality of orientation, and too many learning activities as challenges. For effective flipped learning, the quantity and upload timing of pre-learning materials is important. An excessive amount of pre-learning materials is not appropriate and it is suggested to upload them at least a week before the class. In addition, the quiz conducted at the beginning of the course were intended to ensure that the students read the pre-learning materials and were prepared for class discussion. Therefore, it is inappropriate to present overly challenging quizzes; instead, two or three questions that all pre-learners can answer should be provided. In addition, as the learners may find flipped learning unfamiliar, the quality of the orientation is critical for successful learning. Thus, it is necessary to provide detailed guidance on flipped learning, assessment methods, and illness scrip worksheets including an example on the orientation session.
Regarding the assessment, the students stated that taking a test was very challenging. An alternative approach to assessment is to replace a test with reflective journal writing. Reflective journal writing aims to explore students’ conceptualization and meaning-making regarding what they have learned. Thus, reflective journal writing can serve as an effective assessment method. In this study, both reflective journal writing and a test were employed, which appeared to be overwhelming for the students.
During group presentations, the professor indicated that the students did not focus when other groups were presenting. To address this issue, the professors can encourage questions following group presentations and, at the same time, assign one group to pose questions before each presentation, rotating the responsibility among the groups.
In conclusion, the responses of preclinical students and professors to case-based flipped learning using illness script worksheets were generally positive, and this intervention is thought to be an effective instructional method for fostering clinical reasoning skills in preclinical medical students. As expected, illness script worksheets and collaborative learning in flipped learning appeared to alleviate the cognitive burden of novice students. However, this study is preliminary in nature, and further experimental research is crucial to validate these findings. As a limitation of this study, it involved a relatively small number of participants from a single university. In addition, this study relied on self-reported data, and despite the anonymity of the survey, potential social desirability bias could have influenced the students’ responses.

Acknowledgments

None.

Notes

Funding
The work was supported by the Ministry of Education of the Republic of Korea and the National Research Foundation of Korea (NRF-2021S1A5A8066646).
Conflicts of interest
No potential conflicts of interest relevant to this article was reported.
Author contributions
All work was done by Jihyun Si.

Table 1.
Flipped Learning Activities
Professor Student
Before the class - Develop a clinical case. - Study the pre-learning materials.
- Develop and upload the pre-learning materials.
- Develop online quizzes.
During the class (120 min) - Present online quizzes and check the answers (5 min). - Take online quizzes.
- Provide worksheets with a clinical case on it. - Complete the worksheet as a group.
- Facilitate group discussions (50 min). - Deliver group presentations.
- Provide feedback on group presentations (40 min). - Ask questions during the Q&A session.
- Conduct a mini-lesson (10 min).
- Q&A session (5 min)
Table 2.
Results of Student Survey
No. Items Mean±SD
1 The orientation was beneficial for comprehending the class objectives, flipped learning activities, and assessments. 2.97±0.96
2 The clinical reasoning worksheet was useful in fostering the development of clinical reasoning skills. 3.22±0.92
3 The assessment methods were fair and objective in evaluating the development of clinical reasoning skills. 2.73±0.99
4 I always studied the pre-class materials before the class. 3.51±0.69
5 Working with clinical cases were beneficial in enhance clinical reasoning skills. 3.19±0.70
6 Collaborative learning during the class was effective. 3.38±0.76
7 The instructional format was effective in developing clinical reasoning. 3.03±0.90
8 Reflective journal writing was beneficial for my learning. 2.73±1.05
9 I actively participated in the class. 3.84±0.37
10 Overall, I am satisfied with the class. 2.73±0.90
Total (out of 4 points) 3.13±0.63

SD: Standard deviation.

Table 3.
Results of Professor Survey
No. Results Mean±SD
1 The orientation conducted before the class was helpful in understanding course objectives, flipped learning concepts and activities, and assessments. 3.71±0.18
2 The orientation was helpful in designing my flipped learning. 3.86±0.14
3 The course was designed in alignment with the learning goal of developing clinical reasoning skills. 3.57±0.20
4 The assessment methods were appropriately aligned with the learning objectives of this course. 3.43±0.30
5 The flipped learning activities, both before and during the class, were effective to develop clinical reasoning skills. 3.29±0.18
6 The clinical cases used in class were suitable for the learners’ level and quantity. 3.29±0.18
7 Rubrics employed for assessments increased the validity and reliability of the assessments. 3.00±0.31
8 I implemented flipped learning seamlessly. 3.57±0.20
9 The worksheet was suitable for the development of students’ clinical reasoning. 3.43±0.20
10 Overall, I am satisfied with the course I conducted. 3.14±0.14
Total (out of 4 points) 3.43±0.38
11 What was the most challenging aspect when designing your own class? -
- The complexity of class design
- Apprehension about conducting it for the first time
- Determining the difficulty level of cases that align with students’ knowledge
12 Which aspects do you need more assistance with when designing your class? -
- There are many things to handle both before and after class, such as uploading class materials. More assistance from teaching assistance may be necessary.
- It seems like more class time is needed.
13 What do you consider the strengths of this class? -
- Observing diverse reasoning from students made me think this class is truly effective.
- It is not a one-way lecture; it is a discussion-based class that allows students ample time to think.
- Students were prepared for the class in advance, which reduced my burden during class.
- It is distinctly different from PBL and this class helped adjust the direction in which students think.
- A student-driven class seems beneficial.
14 What do you consider the weaknesses of this class? -
- There was a lack of concentration when listening to other groups’ presentations.
- The instructor needs to prepare a lot, and a significant amount of time and effort is required.
15 If you have any suggestions for improvement, what would they be? -
- The test after class seems to be unnecessary. Group evaluations alone might be enough.
- If time allows, it might be good for the instructor to directly participate in each group's discussion and provide immediate feedback after presentation, rather than giving feedback at the end of the presentations.
- It would be helpful to find a way to ensure that students can concentrate on other groups’ presentations.

SD: Standard deviation, PBL: Problem-based learning.

References

1. Cooper N, Bartlett M, Gay S, et al. Consensus statement on the content of clinical reasoning curricula in undergraduate medical education. Med Teach 2021;43(2):152-159.
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2. Si J. Strategies for developing pre-clinical medical students’ clinical reasoning based on illness script formation: a systematic review. Korean J Med Educ 2022;34(1):49-61.
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3. Sweller J, Ayres P, Kalyuga S. Cognitive load theory. New York, USA: Springer; 2011.

4. Van Merriënboer JJ, Kirschner PA. Ten steps to complex learning: a systematic approach to four-component instructional design. 3rd ed. New York, USA: Routledge; 2018.

5. Hew KF, Lo CK. Flipped classroom improves student learning in health professions education: a meta-analysis. BMC Med Educ 2018;18(1):38.
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6. Levin M, Cennimo D, Chen S, Lamba S. Teaching clinical reasoning to medical students: a case-based illness script worksheet approach. MedEdPORTAL 2016;12:10445.
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7. Charlin B, Boshuizen HP, Custers EJ, Feltovich PJ. Scripts and clinical reasoning. Med Educ 2007;41(12):1178-1184.
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8. Moghadami M, Amini M, Moghadami M, Dalal B, Charlin B. Teaching clinical reasoning to undergraduate medical students by illness script method: a randomized controlled trial. BMC Med Educ 2021;21(1):87.
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9. Al‐Zahrani AM. From passive to active: the impact of the flipped classroom through social learning platforms on higher education students’ creative thinking. Br J Educ Technol 2015;46(6):1133-1148.
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Appendices

Appendix 1. Illness Script Worksheet

kjme-2024-297-Appendix-1.pdf
Appendix 2.

Results of the Focus Group Interview

Question Results
What aspects were beneficial for the development of clinical reasoning skills?
Authentic clinical cases - Engaging in clinical reasoning with real cases was beneficial.
- I understood the importance of considering the prevalence of diseases and focusing on common diseases in clinical reasoning.
- This learning experience was more memorable compared to traditional lecture-oriented classes.
- Learning from a different perspective about what symptoms are more important and how they may not always be definitive was valuable, unlike lecture-oriented classes.
- It was helpful to revisit and review what had been learned thus far through the examination of cases.
Collaborative learning - Group discussions about which diseases are suspected was the most helpful.
- Listening to the reasoning process of group members or other groups helped me identify errors and provided valuable learning opportunities.
Professor’s feedback - Professor feedback played a crucial role in broadening my perspective.
- Through feedback, I could identify what might have been overlooked in my clinical reasoning process.
Worksheet completion - The structured worksheet guided what to do during clinical reasoning, and it was helpful.
- The process of comparing and contrasting differential diagnoses for the three possibilities was helpful in finding the most likely disease.
Reflective journal writing - Writing a reflective journal within 2 days after the class prompted a reconsideration of the entire reasoning processes.
Appropriate difficulty level - The appropriate difficulty level allowed for exploring various differential diagnoses for clinical cases under discussion.
What were the challenging aspects in the course?
Quantity and upload timing of pre-learning materials - One time, the pre-learning materials consisted of a 40-page paper.
- The pre-learning materials were uploaded the day before the class.
Quality of orientation - Given the numerous tasks and diverse evaluation methods in the class, a more thorough orientation would have been appreciated.
Too many learning activities - Compared to traditional lecture-oriented classes, there was a lot to do during the class, including discussions, worksheet completion, and presentations, making it a bit challenging.
- The pre-learning and quizzes felt somewhat burdensome.
Time constraints - It was challenging to discuss, complete worksheets, and present them within a 2-hour class.
- Due to time constraints, the professor could not provide sufficient feedback.
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