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Test-Enhanced Learning in Flipped Classroom

Huffmyer, Julie L. MD; Nemergut, Edward C. MD

doi: 10.1213/ANE.0000000000000662
Editorials: Editorial

From the Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia.

Accepted for publication January 9, 2015.

Funding: Institutional and departmental sources.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Edward C. Nemergut, MD, Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908. Address e-mail to

In this issue of Anesthesia & Analgesia, Vasilopoulos and colleagues1 present the results of an educational study where the authors used podcasts to teach basic electroencephalograph (EEG) interpretation. The authors administered a 25-item multiple-choice test to anesthesiology residents and fourth year medical students at baseline, after podcast viewing, and after a practical EEG interpretation session with a neurophysiologist. At each evaluation stage, the test scores progressively increased. Those learners with a history of more podcast experience (4 or more previous podcasts) showed greater increase in scores compared with those learners with less podcast experience (3 or fewer). While this study possesses compelling results regarding the use of podcasts as an EEG teaching tool, it also demonstrates the effective use of 2 novel teaching techniques: test-enhanced learning and the “flipped” classroom.

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In medical education in the United States, especially graduate medical education (GME), multiple-choice tests have been used almost exclusively as an assessment tool. For generations, successful performance on multiple-choice tests has served as mandatory milestones for continued advancement in medicine. In anesthesiology, candidates must successfully pass both the American Board of Anesthesiology BASIC and ADVANCED examinations to obtain primary board certification. Current diplomats must pass the American Board of Anesthesiology Cognitive Examination every 10 years to maintain board certification in anesthesiology (Maintenance of Certification in Anesthesiology).

In this study, the authors used a multiple-choice test at each stage for the primary purpose of objective learner assessment. The tests were used to document that the subjects were learning something about EEG at each stage. But, is there more to testing than assessment?

There is emerging evidence from cognitive science that strongly suggests that testing may be a very important component of learning.2 Tests, especially pretests, can enhance and alert memory. In 2008, Karpicke and Roediger3 demonstrated the impact of testing on outcome in a foreign language construct. After being exposed to the English translation of 40 Swahili words, students were randomized to 4 groups. Two groups focused most strongly on repeated testing for subject mastery. Two groups relied more on studying for mastery, not testing. At the end of the initial learning phase, all students in each of the 4 groups had mastered all 40 Swahili words. When the students were retested 1 week later, those students who had repeated testing recalled about 80% of the Swahili words. In contrast, those students randomized to groups that focused on studying (i.e., those students who had not been tested as part of the mastery process) recalled only about one-third of the Swahili words.3 The authors concluded “testing (and not studying) is the critical factor for promoting long-term recall.”3 Amazingly, the differences between testing and studying can even be appreciated using functional magnetic resonance imaging of the brain!4

In a similar study, Halamish and Bjork5 demonstrated that cued-recall testing enhanced final examination performance more than studying. Importantly, the authors noted that the effect was greatest when the final examination was most difficult, suggesting that the efficacy for repeated testing is greatest with complicated subjects. The authors concluded that “when there is a fixed amount of time that can be spent restudying or testing, the more difficult the anticipated criterion test, the more initial testing should be chosen.”5

In Fahy and colleagues6,7 body of work regarding EEG instructional models,8–10 long-term retention has been an important area of focus. In 2014, Fahy and colleagues11 noted that much information acquired during residency training must be recalled months or even years after it is initially learned. In that multidisciplinary EEG study, they found that more EEG interpretations with repeated testing over an extended time period resulted in improved long-term retention.11 While developing the Voyager aircraft (the first aircraft to fly around the world without stopping or refueling in 1984), aerospace engineer Burt Rutan said, “Testing leads to failure, and failure leads to understanding.” In the end, learning in any subject may be just that simple.

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The “flipped classroom” is a novel approach to learning where students watch lectures online and at their own pace, typically at home. Class is then reserved for active learning exercises and interactive activities, which illustrate important concepts. The role of the teacher is expanded, and teachers are expected not to merely observe and assess but to actively engage students. The flipped approach has been widely used in medical schools but has been used much less frequently in GME. The process relies on technology as students must have Internet access to view online content and teachers must have the capability and technical resources to produce this content.

In 2012, Prober and Heath12 published a powerful editorial in the New England Journal of Medicine entitled, “Lecture Halls without Lectures—A Proposal for Medical Education.” In the editorial, the authors note that despite all the advancements in technology that have occurred over the past 100 years, medical students and residents are still being trained to be doctors in “roughly the same way they were taught when the Wright brothers were tinkering at Kitty Hawk.”12 While duty-hour restrictions have reduced the amount of time available for educators to teach and the sheer volume of material and information we expect our students and residents to master has increased, effective, time-efficient education represents a daunting charge to those in medical education. Prober and Heath12 suggest that we must find ways to “make our lessons stickier” and introduce the concept of the flipped classroom as a preferred approach.

The study by Vasilopoulos and colleagues1 is a perfect example of a modern approach to education: it uses both a flipped classroom and test-enhanced learning, although it does not explicitly call attention to these educational techniques. In the study, anesthesiology residents and fourth year medical students viewed podcasted lectures at home before an interactive session with a neurophysiologist and were tested repeatedly between educational activities. The pairing of podcasted lectures, active learning and frequent, repeated testing is exactly what GME should include in 2015. That is the power of the current study. It is about how we should endeavor to teach and train our students and residents. Put simply, it is about the future!

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Name: Julie L. Huffmyer, MD.

Contribution: This author helped write the manuscript.

Attestation: Julie L. Huffmyer approved the final manuscript.

Name: Edward C. Nemergut, MD.

Contribution: This author helped write the manuscript.

Attestation: Edward C. Nemergut approved the final manuscript.

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Edward C. Nemergut is the Section Editor of Graduate Medical Education for Anesthesia & Analgesia. This manuscript was handled by Dr. Franklin Dexter, Statistical Editor and Section Editor for Economics, Education, and Policy, and Dr. Nemergut was not involved in any way with the editorial process or decision.

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