title: Does the Concept of the "Flipped Classroom" Extend to the Emergency Medicine Clinical Clerkship?
abstract: BACKGROUND
  Linking educational objectives and clinical learning during clerkships can be difficult. Clinical shifts during emergency medicine (EM) clerkships provide a wide variety of experiences, some of which may not be relevant to recommended educational objectives. Students can be directed to standardize their clinical experiences, and this improves performance on examinations. We hypothesized that applying a "flipped classroom" model to the clinical clerkship would improve performance on multiple-choice testing when compared to standard learning.
  
  
  METHODS
  Students at two institutions were randomized to complete two of four selected EM clerkship topics in a "flipped fashion," and two others in a standard fashion. For flipped topics, students were directed to complete chief complaint-based asynchronous modules prior to a shift, during which they were directed to focus on the chief complaint. For the other two topics, modules were to be performed at the students' discretion, and shifts would not have a theme. At the end of the four-week clerkship, a 40-question multiple-choice examination was administered with 10 questions per topic. We compared performance on flipped topics with those performed in standard fashion. Students were surveyed on perceived effectiveness, ability to follow the protocol, and willingness of preceptors to allow a chief-complaint focus.
  
  
  RESULTS
  Sixty-nine students participated; examination scores for 56 were available for analysis. For the primary outcome, no difference was seen between the flipped method and standard (p=0.494.) A mixed model approach showed no effect of flipped status, protocol adherence, or site of rotation on the primary outcome of exam scores. Students rated the concept of the flipped clerkship highly (3.48/5). Almost one third (31.1%) of students stated that they were unable to adhere to the protocol.
  
  
  CONCLUSIONS
  Preparation for a clinical shift with pre-assigned, web-based learning modules followed by an attempt at chief-complaint-focused learning during a shift did not result in improvements in performance on a multiple-choice assessment of knowledge; however, one third of participants did not adhere strictly to the protocol. Future investigations should ensure performance of pre-assigned learning as well as clinical experiences, and consider alternate measures of knowledge.
authors.affiliation: Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia.
authors.forename: Corey
authors.initials: C
authors.lastname: Heitz
authors.affiliation: Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, Virginia.
authors.forename: Melanie
authors.initials: M
authors.lastname: Prusakowski
authors.affiliation: University of Maryland College of Medicine, Department of Emergency Medicine, Baltimore, Maryland.
authors.forename: George
authors.initials: G
authors.lastname: Willis
authors.affiliation: Virginia Polytechnic Institute and State University, Department of Statistics, Blacksburg, Virginia.
authors.forename: Christopher
authors.initials: C
authors.lastname: Franck
mesh_terms: D002982:Clinical Clerkship / Q000379:methods*; D002983:Clinical Competence; D003194:Computer-Assisted Instruction; D003479:Curriculum; D004635:Emergency Medicine / Q000193:education*; D006801:Humans; D008396:Maryland; D017145:Models, Educational; D014768:Virginia