The Dynamic Classroom for Medical Education: A Tech-Enabled, Data-Driven Version of the Flipped Classroom

Introduction

Three concurrent factors are creating a healthcare crisis in the U.S. First, there is a projected shortage of between 37,800 and 124,000 physicians by 2034, according to Association of American Medical Colleges [1, 2, 3]. This includes between 17,800 and 48,000 primary care physicians and between 21,000 and 77,100 non-primary care physicians. Second, there is a lack of equivalent representation in the U.S. in terms of demographics compared to the physician workforce [4, 5]. This lack of cultural competency and representation leads to negative impacts on medical outcomes, including treatment decisions, treatment adherence, and patient health [6, 7]. Third, there is a gap between the demand for healthcare professionals, especially in low income and rural areas, compared to the labor supply, specifically the number of healthcare professionals graduating and entering the workforce [8, 9, 10].

These three factors are inter-related and range from minor issues, such as longer wait times for appointments with specialists, to major issues, such as not having access to a specialist at all. One solution to address this lack of healthcare professionals, specifically physicians, proposed by the authors is to create a pathway program that allows aspiring physicians an opportunity at a MD year 1 level curriculum. The authors suggest coupling this pathway program with a predictive analytics platform thereby creating an alternative method of evaluating applicants to a medical school. This approach is based on prior research showing that pipeline/pathway programs can be an effective alternative method of accepting students to terminal health science programs [11, 12]. Mayrath, et al. [12] describe a 10 year R&D project at Ponce Health Sciences University (PHSU) to launch a pathway program and build a predictive analytics platform with the goal of increasing diversity of the physician workforce [13, 14].

Like other LCME accredited medical schools in the U.S., PHSU uses standard evaluation criteria such as the MCAT, undergraduate grade point average (UGPA), undergraduate science grade point average (UsciGPA), interviews, etc. However, PHSU also accepts students from the institution’s Master of Science in Medical Sciences (MSMS) program. Launched in 2015-2016, MSMS graduates make up between 20-30% of PHSU’s MD cohorts. MSMS is unique because the program uses the same curriculum as the PHSU year 1 MD curriculum except for 3 courses. We consider the MSMS to be a longitudinal performance assessment program because students must demonstrate mastery of the year 1 medical curriculum. Research shows that a longitudinal performance assessment can be a better measure of a student’s knowledge, skills, and abilities compared with a one-time snapshot of knowledge, such as the MCAT or SAT exam [15, 16].

The PHSU MD admissions committee will waive the MCAT for an applicant from the MSMS program that meets all admissions criteria related to GPAs, interviewed well, demonstrated mastery during the MSMS program, and is predicted to pass the USMLE Step 1 based on the predictive analytics platform. The platform was created & validated by PHSU’s technology partner Tiber Health Innovation. This Case Study builds upon the authors’ previous work by sharing the teaching method & instructional design approach used by PHSU’s MD and MSMS programs. In 2015-2016, PHSU switched from a traditional lecture-based teaching method to a modified version of the flipped classroom. Medical education is evolving as schools move to integrated curricula and add more technology to support teaching and learning. Many medical schools have adopted a flipped classroom teaching method; whereby, students watch lectures videos before attending class meetings face-2-face.

Research on using the flipped classroom approach for undergraduate medical education has shown benefits with students expressing strong satisfaction and generally preferring the method compared to lecture-based instruction [17]. Further, researchers have also found increased student motivation, higher levels of cognitive processing, and more faculty interest as a result of implementing the flipped classroom in undergraduate medical education [18]. However, there is a lack of research on how technology, specifically an audience response quiz system, integrated into the flipped classroom approach can inform faculty & administrators with data. Hypothesis We hypothesize the students will benefit from implementing a modified version of the flipped classroom for undergraduate medical education as measured by performance on the USMLE Step 1 and Step 2 exams. This modified version includes frequent low stakes, formative assessments combined with think-pair-share discussions after difficult quiz questions. Purpose The purpose of the Case Study is to share lessons learned & findings that will hopefully help other medical schools seeking to add more innovation to their MD curriculum. Further, this Case Study builds on the work PHSU is doing to address the lack of diversity in the physician workforce. This report is focused not just on how PHSU MD flipped classroom approach, but how to create an active learning environment that engages students in daily low stakes, formative assessments. Having MD undergraduate students doing quizzes on an almost daily basis does two important things: (a) helps students identify their knowledge gaps.

Results

Data for PHSU medical school cohorts that started between 2015-2016 and 2020-2021 was used to compare MSMS and Non-MSMS groups. A significant difference was found when comparing mean MCAT scores between Non- MSMS (mean score, 497.5) and MSMS (mean score, 487.0) groups (P = .0085). A significant difference was also found when comparing the mean undergraduate grade point averages (GPAs) between Non-MSMS (mean GPA, 3.66) and MSMS (mean GPA, 3.47) groups (P = .0031). No differences were found when comparing the mean USMLE Step 1 scores for both groups: Non-MSMS (mean score, 220.2) and MSMS (mean score, 218.6) students (P = 0.56). No differences were found when comparing the mean USMLE Step 2 scores for both groups: Non-MSMS (mean score, 235.2) and MSMS (mean score, 232.8) students (P = 0.29). A 2-tailed, unpaired 2-sample t test assuming unequal variances was used to test for significance.

Discussion

The authors compared two groups of PHSU MD students: students accepted directly or Non-MSMS and students that were accepted from the MSMS (the pathway program). There was a statistically significant difference between the two groups on MCAT and UGPA; however, there was no statistically significant difference when comparing the two groups on the USMLE Step 1 and Step 2 scores. This finding is important because it shows that there are other MD admissions methods that can be considered other than relying on the MCAT as a cut score. In other words, there is a large population of potential physicians that could address the three problems stated earlier; however, these potential physicians are blocked by a high stakes exam with known biases [7].

Data showed that MSMS students had lower MCAT scores and lower UGPAs compared with their Non-MSMS peers; nonetheless, MSMS students performed comparably on the USMLE Step 1 exam and the USMLE Step 2 exams. The PHSU medical program accepted pathway students with MCAT scores as low as 480 to 490; however, these pathway students benefited from their well-established prior knowledge going into their second year after taking year 1 of medical school twice (once during the MSMS program and then again during year 1 of medical school). We believe that the Dynamic Classroom teaching method and Early Alert system help to explain this finding, e.g., creating an active learning environment supported with formative data & reports help to engage students and remediate.

Acknowledgments

The authors would like to thank the following contributors and collaborators: Dr. Olga Rodriguez de Arzola, Dr. Georgina Aguirre, Dr. Elizabeth Rivera, Dr. Gino Natalicchio, Elizabeth Riebeling, Cole Palmer, and Sam Willis. Funding/Support: None reported. Other disclosures: None reported. Ethical approval: This study was approved as exempt by the PHSU IRB, July 20, 2022, #2207109740.