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Where is the pedagogy in flipped classrooms?


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 Environment. Faculty 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


  • Robert R Cooney

    There’s so much that I could say about this post that may actually be easier for me to write a reply post 🙂

    First, what is pedagogy? According to Merriam-Webster it is the, “art, science, or profession of teaching.” I think too many educational critics focus on the science part at the expense of the art and profession. The tweet posted in the text certainly brings up an important point though. Any educational endeavor should begin with the outcome in mind. Simply using technology for technology’s sake doesn’t help anyone. That being said, I believe that technology can play an important part in the future of medical education.

    As you point out, our current pedagogical preference is the traditional lecture. Fortunately, we are beginning to see a discussion of how best to improve lectures. Whether it is a focus on design principles (i.e. Mayers principles), incorporation of active learning techniques, or a focus on improved delivery, any improvement is a good one. That doesn’t negate the fact, however, that lectures are largely passive in nature. I don’t say this to diminish their importance, especially as a learning tool, but to point out that passive learning can be done as an individual. There are multiple other techniques for active learning, however, these almost entirely depend on interaction with your classmates or co-learners. If we want to improve active learning when learners are together, we still need to ensure that they are adequately prepared for the interaction. This is where online lectures, delivered via podcast or video, make sense.

    So what about the educator making the video being the one who determines the important information. Is this any different from a traditional lecture setting in which the teacher is the sage on the stage? Is it true that the learners have to memorize and remember? To an extent, yes. But if the purpose of the lecture is to prime the learner with the needed information to complete tasks and active learning setting, this is not a problem. It is simply part of a sound pedagogical approach.

    Another argument that you make is that videos shouldn’t be short. This flies in the face of Cognitive Load Theory. This theory posits that our working memory has a very limited capacity. It is taxed even further when the information is new or unfamiliar. Some pedagogical approaches to reduce cognitive load include:

    -Activating prior knowledge as a starting point for learning
    -Arousing curiosity (can be done with interesting clinical case)
    -Focusing attention on important concepts by removing unnecessary details
    -Pay attention to your A/V delivery (Mayer’s principles, again 🙂
    -Try to organize information in a hierarchical format that reveals relationships between the material
    -Reduce redundancy
    -Limit the amount of information being presented chronologically (the argument for short lectures)
    -Promote distributed practice
    -Guide students learning (guided notes instead of sliduments)

    So where is the pedagogy in flipped classrooms? Everywhere! Just as with lectures, educators wishing to use the flipped methodology should pay attention to learning theory in order to maximize the students passive learning time as well as the active learning time. Deidre’s goblins are a good illustration of how the methodology can go awry, and provide insight about how to avoid making the same mistakes. As educators is our responsibility not only to provide the content to be learned, but create an environment in which learning can occur and to model best practices in learning. As to the question of whether a flipped classroom is a pedagogy or a teaching tool, I believe that it is the former. It is a method of taking the best of certain tools (small group discussion, peer-to-peer instruction, and lecture) and combining them in the format that attempts to maximize learning.

    • Javier Benítez

      HI Rob,

      Thank you so much for your comment. I’m always learning lots from you.

      I believe most of the talk about the flip classroom nowadays is about the use of technology and turning the live lecture into a video lecture. As Gibbs pointed out around 20 years ago the lecture is a very passive method of learning. So, if we are only talking about placing the lecture on video we are not changing much. I feel that we are neglecting what should happens in the classroom and how the learner should prepare before coming to class.

      In my opinion if you are telling the learner what’s important then the learning/thinking is already done. Memorization and remembering are important but they should be a result of active learning and not memorization from other’s learning.

      As per video lectures it appears that Mayer calls segmenting having short sequences instead of one continuous long video (see video at min 7:30 and segmenting in article). Although in min 9:30 he does advocate for short videos he does not indicate how long they should be. What I take from this is break down a video into segments within the same video depending on learning objectives. So if the video lecture is on evaluation and management of shortness of breath, segment is history taking on the patient with shortness of breath, segment 2 physical examination on the patient with shortness of breath, and so on. I’m going to look in the literature to see if he indicates how long videos/segments/sequences should be.

      In Deirdre’s example they technically flipped the classroom, but apparently it wasn’t effective. Maybe flip classroom means different things for different people and that’s where concepts and practices get watered down.

      Thanks for your response.

      • Robert R Cooney

        I think you hit the nail on the head. “Flipped classroom” has been watered down in its meaning and people are focusing too much on technology. As you point out, simply putting videos online in place of lectures isn’t changing much. While using Mayer’s principles to improve those lectures by shortening them in minimizing cognitive load is helpful, the real magic of the flipped classroom happens in the classroom. As you know, our program uses a low-tech flip, mainly focusing on reading journal articles to serve as the out of class work. This could easily lead to information overload, although we are cognizant of the amount of time it will potentially take and subsequently reduce our residents expected work hours by about four per week. This gives them the time they need to be able to do the work.

        I believe that learners will take a different approach to the out of class work depending upon their level of familiarity with the material. For learners who are new to the material, memorization and remembering maybe all that they are capable of accomplishing. Learners who are familiar with the material are able to apply higher-level cognitive tasks such as compare and contrast or application. Fortunately, when all of the learners meet as a group, the teacher can design learning activities at these higher-level tasks. This allows the new learners to take what they have “memorized” and apply it to patient care or problem-solving. One of the other benefits of having learners of different stages in the classroom together like this is that the “expert” teacher is no longer the one providing “knowledge.” Instead, “proficient” upper year residents teach the “novice” interns while the attending serves as a guide to ensure that they are actually applying the concepts correctly.

        Again, what happens in the classroom is incredibly important to the success of a “flipped classroom.” I think the exercises provided on Deirdre’s webpage are excellent. Taking time to appropriately design these exercises helps to make the magic happen. A few of the options that she does not list, but I really enjoy, are more project directed application of the concepts. In line with the Next Accreditation System, our residents are expected to take part in quality improvement. Guiding them through the creation of the departmental guideline or checklist can give them these 21st century physician skills that otherwise may be overlooked.

        As for the videos, I like the option of having multiple short videos. First, this reduces the cognitive load. While you could get away with a long video that is segmented, this makes the video less portable as well. For learners at different stages, I would expect novices to need different videos than higher-level learners. Providing an à la cart selection and allowing them to choose which videos they watch gives them some control over their learning.

        Overall, well thought out post and great points for discussion for those considering implementation of the foot classroom!

        • Javier Benítez

          Hey Rob,

          Thanks again for your response. Yes, I would like to focus more on implementation and create habits that foster life-long learning. I also like the fact you give your learners articles to read as this is how physicians acquire their knowledge for change of practice.

          The Internet and technology are giving us more options to present the material in different forms. It’s also giving us the option of how experts interpret the literature and talk about their practice. We are also interacting and learning from each other via the Internet. These are affordances that we now have, but we need to find out what the right practice is. We have to be more cognizant about the limitations of lectures, textbooks, and other traditional practices in order to advance the practice of medicine.

          Integration of the curriculum is also an area that does not get as much attention as it deserves in medical education. There needs to be lots of integration and trimming in the curriculum. It looks like you have that covered at your shop 🙂

          I’m looking forward to reading more of your work.

  • Javier Benítez

    Deirdre Bonnycastle (@Bonnycastle) linked her Wiki page about the Flipped Classroom via Twitter. In the Wiki she provides resources and tools to help the learners before class and make the class more interactive. some examples on what to do in class include creating cases, podcasts, and iBooks. Here’s the link:

  • Javier Benítez

    Just Reich (@bjfr) a fellow at the Berkman Center wrote a post in Education Week titled: Short Videos are Better for Learning, Right? Maybe Not. The post brings up important issues about live and video lecture length, learning, attention span, and engagement. Important parameters that correlate, but we should keep in mind that although necessary for learning, they are not sufficient.