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Letters to the Editor

In Reply to Goldberg and to Hurtubise et al

Prober, Charles G., MD

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doi: 10.1097/ACM.0000000000000231
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I appreciate the specific issues raised by Dr. Goldberg and by Dr. Hurtubise et al. Dr. Goldberg correctly implies that there is a lack of definitive data supporting an optimal teaching strategy. There is, however, increasing literature regarding the effectiveness of hybrid learning models. A meta-analysis published by the U.S. Department of Education concluded that “on average, students in online learning conditions performed modestly better than those receiving face-to-face instruction” with larger effects if the online learning was blended with face-to-face instruction.1 Former Princeton President William Bowen and the nonprofit organization ITHAKA have published studies demonstrating the effectiveness of a combination of online and in-class instruction in learning outcomes with fewer hours of study than traditional in-class instruction.2

Dr. Goldberg expresses concern that “reducing the opportunity … to establish a framework, integrate course content, and then apply this content to problem solving may be counter to effective education.” I agree. Our proposed model is specifically designed to integrate course content, delivered in digestible doses (e.g., as short videos), before engaging the students in the critical, interactive application exercises. This is aimed to ensure that the relevance of the facts to medical practice is evident and that the knowledge is more sustained.

Dr. Goldberg questions several of our general statements about medical education, including our assertion that it is “not compelling,” especially during the preclinical years. This statement is based upon innumerable conversations with our medical students and education deans from across the country. Dr. Goldberg also questions our belief that “much of what will be taught … will prove to be wrong.” One need only consider the recent changes in long-standing recommendations regarding cholesterol control, prostate-specific antigen monitoring, frequency of mammograms, and the value of hormone replacement therapy to recognize that what we “know” continues to evolve. In 2005, Dr. John Ioannidis3 published a manuscript describing the reasons why many published research claims turn out to be wrong. Ioannidis cites literature supporting the concern that “in modern research, false findings may be the majority or even the vast majority of published research claims.”

Hurtubise et al present some positive data regarding the use of the flipped-classroom approach at their school and caution that a “change management approach” will be required to implement this model of teaching more broadly in medical education. I could not agree more. Long-standing practices in medicine and education are difficult to change individually, let alone together!

Charles G. Prober, MD

Senior associate dean for medical education

and professor of pediatrics, microbiology and

immunology, Stanford School of Medicine, Stanford,



1. Means B, Toyama Y, Murphy R, Bakia M, Jones K Evaluation of Evidence-Based Practices in Online Learning. A Meta-Analysis and Review of Online Learning Studies. 2010 Washington, DC U.S. Department of Education, Office of Planning, Evaluation, and Policy Development
2. Bowen WG, Chingos MM, Lack KL, Nygren TI. Interactive Learning Online at Public Universities: Evidence from Randomized Trials. 2012 New York, NY: ITHAKA Accessed March 6, 2014.
3. Ioannidis JP. Why most published research findings are false. PLoS Med. 2005;2:e124
© 2014 by the Association of American Medical Colleges