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FlippedClassroomAs you are aware there has been lots of discussion going on about the concept of flipping the  classroom in education these days. ALiEM recently hosted a book club where Salman Khan’s book (The One World School House: Education Reimagined) was featured in a Google Hangout. Khan, an ex-hedge fund manager, started making videos to help his niece with her math homework years ago. These videos ended up on YouTube and became quite popular. It wasn’t until later with the help of Bill Gates that he formed The Khan Academy and popularized the concept of the flipped classroom.   

Flipped Classroom Model

Flipped classrooms can be generally thought of as a teaching approach where learners are first exposed to new content before class on their own and then process the information in a facilitated, group setting during class.

Dr. Robert Cooney (@EMEducation) discussed in a blog post at iTeachEM his experience with flipping the classroom. In his blog post he writes about the pioneers of this model Eric Mazur (@Eric_Mazur), a Harvard physics professor, and Jon Bergmann (@jonbergmann) and Aaron Sams both high school teachers. In reality the history is not as important as the concept itself for this post. But I would encourage to read the post and watch the hangout from ALiEM and read Cooney’s post for valuable background information. I would also like to emphasize the importance of Mazur and Bergmann because both are active on Twitter, publish academic work, and share their work via blogs and videos. These are the kind of participatory digital practices educators are engaging in these days.

Pedagogy before tech. Pedagogy before tech. Where are the talks on pedagogy? Oh, I forgot, they’re not as pretty & infinitely much harder.

— Adam Holman (@AGHolman) January 25, 2014

What is Pedagogy?

Pedagogy is basically the practice of teaching used to help learners with their lifelong endeavors. I like this tweet above, because it reminds us that by talking about technology we are not necessarily addressing the practice of teaching and learning. Yes, technology is helpful but should be seen as a tool to be employed after an effective pedagogical practice has been set in place. 

Active Learning Strategies

One example of a poor pedagogical approach is the traditional lecture when it comes to learning. It is passive learning and just not effective. This has been a driving force whereby educators are continually searching for more effective instructional approaches, such as flipped classrooms. There are many ways to conduct flipped classrooms and an example of an effective pedagogical approach is described by Eric Mazur where learners co-construct knowledge through active learning instructional strategies. Mazur uses a method which he calls “turn to your neighbor” and also instructs the learners to address the material before coming to class so they are ready for classroom discussion. In my view, although learning before class is quite important, this is the most effective way of learning in the classroom.

Other active learning strategies have been addressed in the literature. One recent example is by McLaughlin et al [1] which also uses classroom activities similar to Mazur’s approach. The image below from McLaughlin’s latest paper shows how different the classroom looks from the traditional classroom. It is also important to note the authors consulted experts in technology and pedagogy for the course redesign.

Another example is by Lukas et al [2], who found a higher correlation of knowledge retention in an active learning setting compared to a traditional lecture-based setting. Steinert and Snell wrote a review of the literature with positive results when interactive techniques in the classroom were used [3]. One of the biggest advantages of using active learning strategies in the classroom is the use of critical thinking. Critical thinking has many advantages including, but not limited to, long term retention, divergent thinking, and problem solving strategies. Stacey Walker [4] performed a literature review on active learning strategies and critical thinking in which she describes effective techniques. Cooney also addressed higher order thinking skills as part of Bloom’s Taxonomy in the Google Hangout and the iTeachEM post, which are also part of critical thinking classroom activity.  

Although not a new concept, active learning strategies have been difficult to implement as documented by Graffam [4]. It has also been found that learners do not favor these techniques over passive strategies. Furthermore, their scores in multiple choice/true-false tests do not improve significantly [5]. The implementation of these learning strategies require a lot of work and buy in from faculty and learners [1]. More research needs to be done on active learning strategies as they might add value to lifelong learning even if not demonstrable on psychometric measures [6,7].   

Flipped Classroom: Information Overload

Deirdre Bonnycastle (@Bonnycastle), an educator from Canada’s University of Saskatchewan, wrote a post about her students’ experience with flipping the classroom (The Flipped Classroom Goblin). In her post she identifies 4 themes with details ranging from learners feeling overwhelmed with the material to lack of faculty development and integrated curriculum. One of the themes was “Too Much Content”. I believe this is a legitimate concern. Information overload has always been present in medical education, but we should really refer to it as filter failure. We can train and create educational curriculum to be better filters as information overload will always be present and we don’t have the capacity to learn it all. 

Role of Textbooks

When it comes to acquiring information, physicians spend most of their time reading material. Textbooks have placed a very important role in establishing a strong foundation for knowledge acquisition. The use of books varies from program to program and even from person to person, but the foundation needs to be there. It is important for the learners to be efficiently guided by an expert through the reading as the material is vast. Regardless of its limitations such as price and being out of date, the textbook continues to play a primary role in medical education. It has such advantages as being correlated with a curriculum, having a well organized structure, presenting information in one place, and being peer reviewed. The textbook may be an important tool if appropriately used as a piece of the curriculum and rather than as the entire curriculum. It starts losing its value when learners are not guided appropriately, for example when assigning readings without purpose or consideration of volume.  

Reading with a Critical Eye

Since reading is so important and not everything we read is valid or relevant, learners should be guided how to make these distinctions. Review books and exams are doing the thinking for us, so unfortunately we are left with memorizing and remembering the information. For example, illness scripts can be memorized, but in reality it takes years of experience, deliberate practice, and reflection to develop one’s own illness script. As learners advance and acquire the tools to read journal articles with a critical eye, they should start to build a repertoire of well-written articles in their vocabulary. This is a hallmark of experts’ discourse. Great examples of this display is found in discussion between experts on podcasts, blog comments, videos, and article replies. As the Internet provides us with great resources that may be used before class, it is imperative to teach the learners how to determine the validity and affordances of these as well.

Flipped Classrooms and Video

The use of videos is also being explored in the flipped classroom model. There are certainly plenty of advantages to the use of videos as learning objects. Technology, such as the use of videos, helps us visit the information in a different format, watch at our own convenience, and share with others. McLaughlin et al reduced the hours of live lectures quite significantly when they were converted to video lectures [1]. But in my opinion the person doing the video is the one doing the learning as this is the person who is determining what’s important. The learners watching the video have only to memorize and remember the information as it may not lead to a discussion unless a dialogue between author and learner occurs. It has also been suggested for these videos to be short. My argument is if they are short, why not just present in class? I’m also not convinced a short video gives enough information for someone to have a meaningful discussion for co-construction of knowledge in class. In my view medical practice is too complex (complexity) and instead of moving towards a reductionist practice we should embrace the uncertainties involved in it. For example there is really not one way of taking a history or performing a physical exam as not every question or physical exam maneuvers have the same diagnostic likelihood ratio. I thus am an advocate for longer, deep-dive videos as a foundation for better in-classroom discussion if videos are to be used. There are examples of deep-dive videos, podcasts, blog posts in the Internet that should be explored as educational resources.

Where is the Pedagogy in Flipped Classrooms?

So now I return to the question in the title of this blog post. I think the”flipped classroom” brand has arisen as a response to faulty pedagogical practices in our classrooms. In fact, flipped classrooms themselves are not a pedagogical practice per se but more just a tool. As a tool, it depends how on it is applied by the user (instructor), and there are many ways one could go wrong. This might include information overload, not providing a guided reading curriculum or foundational knowledge on how to critically appraise resources,  incorporating only superficial videos as learning objects, and not incorporating active learning instructional strategies during classroom time. Remember two things:

  1. What happens OUTSIDE of the classroom is as important as what happens IN it.
  2. Technology is not THE answer, but it can be PART of the answer if used appropriately. 

Let me know what you think. 


  1. McLaughlin et al. The flipped classroom: a course redesign to foster learning and engagement in a health professions school., Acad Med. 2014 Feb;89(2):236-43., PMID: 24270916 
  2. Lukas et al. Correlation between active-learning coursework and student retention of core content during advanced pharmacy practice experiences., Am J Pharm Educ. 2013 Oct 14;77(8):171., PMID: 24159212
  3. Steinert Y, Snell L. Interactive lecturing: strategies for increasing participation in large group presentations., Med Teach. 1999, Vol. 21, No. 1, Pages 37-42.
  4. Graffam B. Active learning in medical education: strategies for beginning implementation., Med Teach. 2007 Feb;29(1):38-42., PMID: 17538832 
  5. Haidet P. A controlled trial of active versus passive learning strategies in a large group setting., Adv Health Sci Educ Theory Pract. 2004;9(1):15-27., PMID: 14739758 
  6. Prince M. Does active learning work? A review of the Research., Journal of Engineering Education Volume 93, Issue 3, p 223–231, July 2004
  7. Norman G. What’s the active ingredient in active learning?, Adv Health Sci Educ Theory Pract. 2004;9(1):1-3., PMID: 14983855 

For Further Reading: 

  1. Gleason B. An active-learning strategies primer for achieving ability-based educational outcomes., Am J Pharm Educ. 2011 Nov 10;75(9):186., PMID: 22171114 
  2. Walker S. Active learning strategies to promote critical thinking., J Athl Train. 2003 Jul;38(3):263-7., PMID: 16558680
  3. Desselle B. Evaluation of a faculty development program aimed at increasing residents’ active learning in lectures., J Grad Med Educ. 2012 Dec;4(4):516-20., PMID: 24294432 
  4. Honeycutt B, Garrett J. Expanding the Definition of a Flipped Learning EnvironmentFaculty Focus, 31 Jan 2014
  5. Krisberg K. More than memorizing facts: medical schools emphasize research and critical thinking as foundations of learningAssoc of Amer Med Coll, 31 Jan 2014.,

Video Active Learning:

  1. Active Learning Classrooms: Everyone is engaged!
  2. Active Learning Environments, Part II: Creating Learning Spaces
  3. Lecturing & active learning


Javier Benitez, MD

Javier Benitez, MD

ALiEM Featured Contributor
Javier Benitez, MD
Javier Benitez, MD