Abstract

Objectives

This study aims to evaluate the effectiveness of a non-traditional medical education method, as simulation-based training combined with flipped classroom model compared with traditional didactic lecture.

Materials and Methods

A pre-test was applied to all participants at the beginning of the clerkship and a post- test at the end. Participants were divided into two groups; intervention group and control group. The intervention group had access to guidelines about sepsis and the practical training was provided with a simulation-based scenario session. A traditional lecture was provided to the control group. Last year medical students who were doing their compulsory clerkship of Department of Emergency Medicine at Ankara University Faculty of Medicine between February 1, 2021 and March 31, 2021, were included in the study. SPSS Statistics Version 22 (IBM, USA) was used for statistical analysis. McNemar test was used for categorical variables and Wilcoxon test for ordinal variables in paired samples. Two tailed Mann-Whitney U test and chi-square test were used for inter-group evaluations.

Results

Participants in the intervention group were more successful than the control group considering post-tests results. Success in the difficult questions was higher in the intervention group. Participants trained with sim+ flipped model were more satisfied regarding the training from the control group. No statistically significant difference was found between the groups in other compared parameters.

Conclusion

Students would benefit more from the education given with simulation based training combined with flipped classroom, compared to conventional didactic method.

Introduction 

Sepsis arises from an unregulated host response to infection, leading to life-threatening organ dysfunction (1-3). Septic shock is a subgroup of sepsis with circulatory and cellular/metabolic dysfunction (4). Sepsis and septic shock pose significant health challenges, impacting millions of individuals globally annually. Early diagnosis and proper management within the initial hours contribute to enhanced outcomes (5). One of the most important conditions for the rapid initiation of treatment is related to the clinician’s awareness. Physicians in charge of potential critical patients have to be competent about the diagnosis and the management of sepsis. In order to achieve this, the clinician must have undergone an effective training. Although the teaching/learning methods applied for this purpose and for general medical education are the most important stage in the training of the clinician, there is not yet a consensus in the literature about which method is the most effective (6).

Simulation is one of the important tools used in medical education. Simulation emulates a clinical encounter and is characterized as a method that substitutes or enhances genuine experiences with guided scenarios, reproducing aspects of reality interactively (7). Simulation-based medical education provides authentic training within an enriched setting, fostering experiential learning and reflective practices, thereby better preparing students for actual patient care (6). Moreover, the simulation laboratory provides students a safe environment where they can enhance their learning through the rational application of the skills necessary to efficiently assess and treat an unstable patient (8). In addition to being an effective and well- experienced education method of traditional medicine education; with the developing technology, the use of simulation-based medical education method is increasing due to the safe and supportive environment provided by this method (9-11). 

Another important tool used in medical education is the flipped classroom method. The flipped classroom approach is a hybrid teaching/learning technique employed to familiarize students with content prior to participating in in-person sessions. While existing literature endorses the flipped classroom as an educational method, there is insufficient research on its application for skill acquisition (12). Moreover, the flipped classroom is defined as a method that creates the opportunity for the student to learn the theoretical knowledge by herself/himself at home and apply what she/he has learned at school, unlike conventional teaching method (13). The essence of this approach, which liberates the instructor from imparting fundamental information, also demands effort from the learner. This not only fosters increased engagement in individual learning but also cultivates proficiency in utilizing technological tools, establishing a more robust foundation for interaction during instructional sessions (14). The objective of this study is to assess the efficacy of an unconventional medical education method, as simulation based training combined with flipped classroom model compared with traditional didactic lecture of managing first hour of sepsis.

Materials and Methods

Study Design, Setting, and Population

The research conducted at Ankara University Faculty of Medicine has been reviewed and approved by the Human Research Ethics Committee under the reference number I11-662-20. Medical students undertaking the Emergency Medicine clerkship at a Fauclty of Medicine between February 1, 2021 and March 31, 2021 were extended invitations to partake in the study. The study was started with the approval of the university where the study conducted. Informed consent was obtained from the participants.

A pre-test with 25 multiple choice questions related to the first hour management of sepsis was applied to all participants at the beginning of the clerkship rotation. Then, the students were divided into two groups through block randomization; simulation-based training combined with flipped classroom group [sim+ flipped classroom; intervention group (IG)] (n=39) and didactic training group [control group (CG)] (n=40). The IG had access to simplified guidelines about the first hour of sepsis management and 3 days after the pre-test, the practical training was provided with a simulation-based scenario session. A simulation mannequin [Laerdal SimMan® 3G mannequin (Laerdal, USA)] was used in this tutorial. A traditional lecture 3 days after the pre-test was given by an emergency physician experienced in sepsis management to the CG. Due to the current pandemic at the time of the study the lecture was given online. A public video communication application was used for this process [Zoom®, Zoom Video Communications, Inc. (San Jose, California, USA)]. All of the participants undertook a -25 multiple choice question- post-test at the end of the clerkship rotation. This test was prepared with the same questions as the pre-test, however the placement of the questions and their answers choices differed from the pre-test. A score over 60 out of 100 was considered successful. Besides total scores, the ability to answer correctly to the most difficult questions was evaluated. Criteria for a question to be considered as a difficult one was to have an item difficulty index ≤0.29. The item difficulty index of the questions was calculated through the utilization of the Henryson method (15). Out of 25 questions, 4 questions were mentioned as most difficult ones. The Delta value of difficult questions were evaluated for each participant. The delta value was defined as; (number of questions answered correctly out of 4 difficult questions in the post-test)- (number of questions answered correctly out of 4 difficult questions in the pre-test). Along with the post-test, the participants were asked to determine their degree of satisfaction and presumed benefit from the training. Visual analog scale from 0 to 10 was used for this evaluation.  

Data Analysis

Statistical analysis of the obtained data was conducted using SPSS Statistics Version 22 (IBM, USA). A power analysis of independent sample t-tests, with an alpha level of 0.05, an effect size of 0.50, and a power of 0.80, indicated a required total sample size of -72. McNemar test was used for categorical variables and Wilcoxon test for ordinal variables in paired samples. Inter-group assessments were conducted using the two-tailed Mann-Whitney U test and chi-square test.

Results 

Of the 88 last-year medical students enrolled in the clerkship, 79 willingly joined the study. All participants provided their informed consent. They were randomly assigned to the IC (n=39) and to the CG (n=40). Two students from the CG could not complete the study because of absenteeism on examination day (Figure 1).

The average age of the participants was 25.23 (0.43), 56% of the students enrolled were female and 95% of them did not have any experience in simulation practice (Table 1).

Participants’ post-tests’ mean scores were higher in both IG and CG. Students who were in the flipped classroom and had simulation practice had a higher increase in post-tests’ scores compared to the ones who underwent the didactic lecture. The delta value of the most difficult 4 questions in the IG was found to be significantly higher than the control group (p=0.048). Participants trained with sim+ flipped model were more satisfied regarding the training from the control group (Table 2).

Discussion

Sepsis, emerging from a spectrum of endemic and epidemic diseases, has left a deep imprint on the course of human history. Today, sepsis continues to significantly contribute to illness and death on a global scale. The exact number of people affected by sepsis is not known. In addition, the increase in antimicrobial resistance and nosocomial sepsis has been a concern; researches suggest 10 million people worldwide will die from health-related infections each year by 2050’s (16).

During the past several years, numerous extensive studies have demonstrated the crucial role of prompt diagnosis and management in the successful treatment of sepsis. The Surviving Sepsis Company provides valuable resources for enhancing the diagnosis and treatment of sepsis, particularly in cases of severe sepsis and septic shock in patients. Nevertheless, based on existing scientific evidence, a substantial portion of patients, around 30% to 40%, does not receive care, and an estimated 20% to 25% of the administered care may be unnecessary or potentially harmful for the patient (17).

Therefore, correct and on-site management of sepsis patients will protect the health system and humanity from the burden of serious morbidity and mortality due to sepsis. For prompt and accurate management of sepsis, health- care providers, especially doctors, should receive an effective and adequate education about sepsis. In the current study, learners trained with sim+flipped classroom method on the management of the first hour of sepsis showed better post-tests results than the CG.

Pre-test and post-tests comparison are instruments useful to measure changes and knowledge gains.  According to our results, mean scores in the post-test, were higher in the IC with a mean score of 69 than in the CG with a score 63.1, however this difference showed no statistically significant difference (p=0.14). It has been observed that some of the similar studies in the literature have superior results for IG and some for CG (18, 19).

The delta value of difficult questions was found to be statistically significantly higher in the participants in the IG (p=0.048). Similarly, Liebert et al. (20) evaluated the efficacy of a flipped classroom method applied in surgical clerkships of third year medical students. Their results showed a significant increase in mean delta values for each module after flipped classroom training.

Participants were considered successful or unsuccessful according to their scores in the pre-test and post-test respectively ≥60 and <60.  No significant difference was found between the IC and the CG for the pre-test (CG= 15, IG= 12) (p=0.479). However, participants became successful in the post-test in both groups (CG= 25, IG= 34) (p=0.03). In a research conducted by Zhao et al. (21) and published in 2020, which the combined problem-based with case-based learning method was compared with traditional education, the difference between the participants’ post-test success was examined. Similar to our study, the group who underwent traditional education was found to be more unsuccessful in the post-test, however the difference between the two groups was not statistically significant (21).

Many studies comparing simulation based education with traditional education have shown medical students to score equivalent or higher on post-tests (22-25). Learning through didactic methods primarily relies on explicit memory, involving the direct recall of previously acquired information. Practical training using simulation facilitates the formation of implicit memory originating from subconscious cognitive processes. Implicit memory is activated through the observation of cues and their association with suitable actions, as opposed to the direct presentation of information through oral or written means. Given the extensive preclinical content, students frequently encounter challenges in determining how to allocate their time and efforts. After experiencing simulations rooted in authentic clinical scenarios, students can grasp the significance and practical relevance of delving more profoundly into the simulated subjects (26).

In comparing teaching/learning methods, besides performance or score improvement it is important to assess whether the method provided appeared beneficial to the pariticipants. For this purpose, the students who participated to the study were asked to score the benefit they thought they received from the training, along with the post-test. We used a visual analog scale, who perceived the benefit at the highest level were asked to give 10 points, and those who perceived the least level of benefit were asked to give 0 point. Considering the mean scores given by the participants (CG= 6.7, IG= 9.05), it was determined that the IG reported a statistically significant higher level of benefit compared to the CG (p<0.001). In a study published by Ramnanan and Pound (27), the students were satisfied with the use of activities based on small group discussions in face-to-face sessions of flipped classroom model; in addition, it was concluded that these sessions helped to increase their motivation to learn, increase their participation level and increase their interest in the subject (27). However, in a study conducted by Fahy et al.(28), certain limitations of the flipped classroom method were identified, especially among reserved students hesitant to engage in discussions with their peers during class sessions.

Study Limitations

This study was conducted at a single center with a limited number of participants; therefore, the results need to be validated in randomized multicenter studies. Another issue that should be emphasized is that traditional education was given online, not face-to-face, due to the current COVID-19 pandemic at the time of the study. This study, centered around sepsis management, consequently, its results cannot be extrapolated to encompass all of medical education.

Conclusion

Although our study was carried out with a limited number of participants (n=77) in a single center, some important evidences were obtained showing that students would benefit more from the education given with simulation based training combined with flipped classroom  in medical schools, compared to conventional didactic method. Considering all the parameters in this study, although the flipped classroom method was found to be more successful than the didactic method for the management of the first hour of sepsis, multicenter studies with larger samples are needed on this subject.