Research article
Open Access

Flipped-classroom combined with case-based learning in human parasitology course for international students

Donghui Zhang[1], Abhinav Kaushik[1], Zhipeng Xu[2], Min Li[1], Minjun Ji[2], Lin Chen[2]

Institution: 1. School of International Education, Nanjing Medical University, 2. Department of Pathogen Biology, Nanjing Medical University
Corresponding Author: Dr. Lin Chen ([email protected])
Categories: Curriculum Planning, Learning Outcomes/Competency, Teaching and Learning, Basic and Foundation Sciences, Undergraduate/Graduate
Published Date: 15/06/2021

Abstract

Background: Increased presence of foreign students in Chinese educational institutions creates new challenges for domestic educators. Through more than ten years of teaching practice, in order to enhance the quality and long-term outcome of medical parasitology course, we have been incorporating adjustments in the contents and teaching methods to better respect diverse culture backgrounds and accommodate epidemiological differences.

Methods: We selected malaria as a topic of learning and designed a case of malaria with high fever as the onset symptom based on a case at the First Affiliated Hospital of Nanjing Medical University. Traditional lecture-based classroom and flipped-classroom combined with case-based learning (CBL) were compared based on questionnaires and scores as well as the effects on the abilities of clinical thinking, communication, active learning and team work. We improved our assessment methods, for flipped classroom combined with CBL model, the final score comprised of final examination marks (paper based and computer-based exam), lab exam, lab report and the group presentation which is the most important aspect of advancement. Group presentation was divided into subcategories: the grade assigned by teacher according to the quality of the presentation, ability to distill the most important ideas of the case and the questions group use to motivate class discussion, the grade assigned by the other members of the group; the grade based on classroom participation when other groups were presenting.

Results: International students were interested in this topic and were more satisfied with flipped-classroom combined with CBL. Compared to traditional lecture-based classroom, more students agreed that flipped classroom combined with CBL could help improve their initiative learning, enhance their ability of communication, promote their abilities of clinical thinking, searching literatures, presenting, team work and student-teacher interaction. The new assessment method improves students' learning enthusiasm and emphasizes the evaluation of their usual grades, more in line with the practical requirements, and narrowed the performance gap between low- and high-performing students in human parasitology course.

Conclusions: Flipped-classroom combined with CBL model is suitable and effective for international students to learn human parasitology course.

Keywords: flipped-classroom; CBL; human parasitology; international students

Introduction

With the development of economic globalization, the exchanges in the field of education are increasing worldwide. The continuous improvement of higher education quality in China has attracted more students to study in China, especially for medical students (Fan et al., 2013). The education of international students has become an important part of higher medical education (Meo et al., 2019). Nanjing Medical University began to recruit international students in 2015. By September 2019, the Institute of International Education of Nanjing Medical University has enrolled more than 1,600 students from 40 countries. The students enrolled are mainly undergraduates with major in clinical medicine taught in English (Medical Bachelor and Bachelor of Surgery, MBBS). International students have different cultural and educational background, religion, learning needs and educational expectations, which pose new challenges to their education (Lin et al., 2019). 

 

Human parasitology is a basic course of preventive medicine and clinical medicine (Hotez, 2018). The purpose of this course is to help clinical students master the knowledge of human parasitic diseases and lay a foundation for future clinical practice through learning the morphology, life cycle, pathogenicity, diagnosis, treatment, epidemiology and prevention of medical parasites (Peng et al., 2012; Zhao et al., 2012). Through more than ten years of teaching practice, we tried to improve medical curriculum and teaching methodology. For example, according to regional characteristics of human parasitic diseases, in the protozoa section we added the trypanosomiasis which is prevalence in African countries, and we added Schistosoma mansoni, Schistosoma hematobium, Babesia, Spirometra mansoni and river blindness in the teaching plan. Moreover, we introduced the latest progress on research on human parasites into the course. 

 

It is common in Chinese colleges and universities that a small number of teachers are responsible for imparting a heavy load of information to a great number of students (Wu et al., 2014; Chen et al., 2018). Extensive lectures often overburden the students, resulting in reduce learning efficiency (Stuart and Rutherford, 1978). Furthermore, traditional didactic teaching mode impedes the development of important abilities in the students, including independent learning, problem solving, critical thinking and communication skills, which is detrimental for their lifelong learning and clinical practice (Hou et al., 2014). If medical students only learn theory without any links to clinical practice, they may know nothing about diagnosis and treatment, and lose the motivation and ability to be a good doctor. Case-based learning (CBL) may narrow the gap between theoretical knowledge and clinical practice. Compared with traditional teaching method, CBL provides a practical model for students to connect content learning to professional practice and is a more effective teaching method to improve the ability of clinical problem-solving and critical thinking of the students (Thistlethwaite et al., 2012; Yoo and Park, 2015). Several studies have shown that CBL “improves clinical performance and enhances clinical knowledge” (McLean, 2016) and are more “goal-oriented” (Srinivasan et al., 2007). In CBL model each student may contribute equally to the diagnosis of a patient and become “content expert” (Jhala and Mathur, 2019). Flipped-classroom is a modern style of teaching, which requires students to preview in advance, discuss and present, and emphasizes student-teacher interactions (Ferrer-Torregrosa et al., 2016). CBL may or may not need pre-class learning, however, in flipped classroom mode, teachers send the foundation content to students before class, and students need to explore active learning strategies. The assessment of students will also include diverse approaches and feedback (Rathner and Schier, 2020). 

 

In this study, we investigated beneficial effects of flipped classroom combined with CBL as a means of teaching human parasitology course for MBBS international students.

Methods

Participants 

We assigned 90 third-year students (grade 2017) in Institute of International Education of Nanjing Medical University as experimental group in flipped classroom combined with CBL, who were scheduled to study Human Parasitology between September and December 2019. The control group of 100 third-year students (grade 2016) in Institute of International Education of Nanjing Medical University learned Human Parasitology in a traditional lecture-based classroom between September and December 2018. 

Study design

We selected malaria as a topic of learning. We designed a case of malaria with high fever as the onset symptom based on a case at the First Affiliated Hospital of Nanjing Medical University. The objective was to enable the students to analyse clinical problems. In traditional lecture-based classroom, after the study of Plasmodium falciparum, the teacher showed the case through PowerPoint presentation (PPT) and students discussed in class.

In flipped classroom combined with CBL, before the classroom session, instructions on information retrieval, clinical thinking, analyzing skills and presentation (Jiang et al., 2017), lecture PPTs, cases and videos were shared on the website. Students were divided into small groups and each group was assigned a topic, such as clinical manifestations, morphology and pathogenesis, diagnosis and differential diagnosis, prevention and treatment, epidemic of the disease, basic knowledge of related disease in the student’s home country. The students were supposed to acquire deep knowledge via the books and internet, and prepare PPT for discussion in class. During this process, students could ask questions and discuss with teachers on the course website. In class, representative from each group made presentationfollowed by cross questioning by the teacher and the classmates. Finally, the teacher summarized the key and difficult points in learning about the disease (Figure 1).

Figure 1. Flow diagram illustrating the study design.

 TG: traditional lecture-based classroom group, FG: flipped classroom combined with CBL

 

Composition of final grade 

For traditional teaching classroom model, the final score of parasitology course comprised of 75% of final examination marks (paper-based exam), 20% of lab exam and 5% of the lab report. 

 

For flipped classroom combined with CBL model, the final score of parasitology course comprised of 55% of final examination marks (paper based and computer-based exam), 20% of lab exam, 5% of the lab report and 20% of the group presentation which is the most important aspect of advancement. Group presentation was divided into subcategories: 40% of the grade was assigned by teacher according to the quality of the presentation, ability to distill the most important ideas of the case and the questions group use to motivate class discussion; 40% of the grade was assigned by the other members of the group; 20% of the grade was based on classroom participation when other groups were presenting (Figure 2).

 

Figure 2. Composition of final grade. 

 TG: traditional lecture-based classroom group, FG: flipped classroom combined with CBL

 

Data analysis

The final scores of each student in traditional lecture-based classroom and flipped classroom combined with CBL group were compared by an independent samples t-test. After class, students were required to complete anonymous questionnaire to evaluate their perceptions and experience (Hu et al., 2019). All statistical analyses were performed using GraphPad Prism 8.0.1., and p< 0.05 were considered significant.

Results/Analysis

Demographic information of students

Total 90 third-year MBBS students were enrolled in flipped classroom combined with CBL group, and 100 third-year MBBS students were enrolled in traditional lecture-based classroom group. No differences were found in gender (p=0.789) or age (p=0.717) between two groups (Table 1).

Table 1. Demographic information of students.

 

TG

FG

Statistics

 df

P value

Gender

 

 

 

 

 

  Male

41

29

 

 

 

  Female

59

61

chi-square=1.569

1

0.789a

  Age(y), mean±SD

21.44± 0.241

21.35± 0.154

t=0.3624

188

0.717b

TG: traditional lecture-based classroom group, FG: flipped classroom combined with CBL

a: These two groups were compared using the chi-square test

b: These two groups were compared using independent samples t test

 

Evaluation of the effectiveness of the course

All 190 students submitted the questionnaires. As shown in Table 2, compared to traditional lecture-based classroom, more students agreed that the flipped classroom combined with CBL could help improve their initiative learning (P < 0.001), enhance their ability of communication (P < 0.001), promote their abilities of clinical thinking (P < 0.001),searching literatures (P < 0.001), presenting (P < 0.001), team work (P < 0.001) and student-teacher interaction (P < 0.001). The students in the flipped classroom combined with CBL spent significantly more time preparing for class than those in the traditional lecture-based classroom (P <0.001). However, there were no significant differences in helping understanding the contents (P = 0.117) and the ability of self-learning (P = 0.145) between two groups. 

Table 2. Comparison of students’ satisfaction survey between traditional lecture-based classroom and flipped classroom combined with CBL.

 

Survey items

TG

FG

χ2

P value

Q1

Initiative learning

34.1%

86.5%

20.121

0.000

Q2

understanding and mastery of the content learned

89.2%

93.6%

3.125

0.117

Q3

Spare time spend on this course

12.3%

95.1%

47.351

0.000

Q4

Promote the ability of communication

35.6%

85.3%

22.106

0.000

Q5

Promote the ability of self-learning

85.4%

94.2%

2.352

0.145

Q6

Promote the ability of clinical thinking

55.7%

90.5%

12.224

0.000

Q7

Promote the ability of searching and reading research papers

32.1%

85.2%

19.861

0.000

Q8

Promote the ability of presenting

10.1%

75.6%

32.452

0.000

Q9

Promote the ability of team work

31.2%

96.3%

26.785

0.000

Q10

Student-teacher interaction

48.6%

86.3%

13.178

0.000

 

The final scores of two groups were shown in Figure 3, there was no significant difference in average score in traditional lecture-based classroom group (80.95 ±11.23) and flipped classroom combined with CBL group (77.47±8.679) (p > 0.05).

Figure 3. The final scores of students in TG and FG group.

 TG: traditional lecture-based classroom group, FG: flipped classroom combined with CBL

 

Analysis of supplementary open-ended questions

In order to further understand student attitude on flipped classroom combined with CBL and the composition of final grade, we collected and analyzed student feedback by open-ended questions at the end of the satisfaction survey. Most students believed that the skills of presentation and teamwork are important in a doctor’s career, and recommended flipped classroom combined with CBL. (student’s statements are kept unchanged in sentences in italics)

It is an imperative skill to be able to demonstrate and clarify concepts to future colleagues, patients and their relatives. Presentation skills are an invaluable asset, I think, for every occupation as it a specific method of communication to convey ideas, so chances to hone this ability to present ideas with ease and clarity should be welcome, even if you are not very good at it or if you have stage fright or a fear of public speaking. It is always better to have exposure to these kinds of experiences than to stay sheltered for now and land in a mess later when you are a doctor and you can't effectively break down and explain a patient's symptoms, complications and so on.

Also lazy people cannot be lazy anymore and they’ve to help their teammates.

It's really great you should continue it in future also...

I think group presentation was the most interesting thing I did for the semester.

I enjoyed the presentation aspect of this class as it gave us an. Opportunity to get out of our comfort zones, and bring out a more creative side of ourselves that we can't explore and project in our other courses.

Students also gave us some suggestions for the future flipped classroom combined with CBL, they thought we should prepare more cases and gave them longer time to present.

Yes, it is good. But it would be better if the groups had more parasites to talk about, For example like few groups malaria, other groups about some other parasites.

It’s excellent. But the time duration for that is not enough.

If you could give different parasites for different groups, maybe we will learn more.

The group presentation score in flipped classroom combined with CBL was divided into 3 subcategories: the grade assigned by teacher, the grade assigned by other members, and student’s classroom participation. For the second part, all students gave a brief explanation of the grade they assigned to the members of their group. Few students worried about the fairness of the grade and complained about their classmates. 

I think everyone of us gave our best to make it a better presentation, I believe it wouldn’t have happened if not for a great team.

We all put more effort into diagnosis, lifecycle and the new findings. The group members were always available to provide information and provide suggestions when needed.

All of us has worked equally to contribute to this success where we all have diagnosed it each part together to diagnose the disease and to find the reason behind it. and not to forget we all worked equally to find new findings and prepare a simple ppt for everyone to understand it clearly and can remember almost everything.

Everyone did their best as a team effort. No one missed their duties. Equally contributed. That's why every one of us could answer for the questions which teacher asked.

Nevertheless, few students worried about the fairness of the grade and complained about their classmates. 

It’s fine but the marking should be very fair so that each and every student benefit.

A did not do anything in the presentation. 

Discussion

Increased presence of foreign students in Chinese educational institutions creates new challenges for domestic educators whose monolithic culture background provides minimal exposure or awareness of dietary restrictions of religious nature. As a result, many instructors of medical parasitology do not fully appreciate the influence of religions on parasitic transmissions. Epidemiological differences also make some parasites and their vectors less relevant to some foreign students. This indicates the medical parasitology course for foreign students should not simply be an English version of the course for Chinese students. In our fifteen years of teaching practice, in order to enhance the quality and long-term outcome of medical parasitology course, we have been incorporating adjustments in the contents and teaching methods to better respect diverse culture backgrounds and accommodate epidemiological differences. During the teaching process, we found that some of the international students have received basic medical education before they come to China, while some, such as Pakistan students, come to study clinical medicine directly after graduation from high school. Therefore, the knowledge background of the students in the international student class are quite different, but most foreign students are diligent in thinking and strong-minded. Different from Chinese students, they will interrupt the teacher's explanation at any time in class and put forward their own questions and different understandings. Therefore, we are constantly trying to find teaching and assessment methods that are more suitable for them.

Traditional medical training focuses on getting good test results, instead of developing professional competencies. Some medical students could not adapt to the doctor's work after graduation. They could not analyze cases, make diagnosis and treatment, or communicate with patients and colleagues. A variety of efforts have been made to shift the curriculum of medical training from a teacher-centered to a learner-centered model (Ferrer-Torregrosa et al., 2016; Jiang et al., 2017; Angadi et al., 2019; Gartmeier et al., 2019). CBL based on specific cases has been widely used in medical education (Preeti et al., 2013; Bonney, 2015; Berman et al., 2016), which is characterized by effective interactive teaching (Gade and Chari, 2013). In flipped classroom, teachers provide class materials and requires students to study before class, and focus on application, discussion, or problem solving during class (Riddell et al., 2017). Flipped classroom model changes students from passive to active learners and has been used in preclinical, clinical, and graduate medical education (Leung et al., 2014; Morgan et al., 2015).

In this study, we combined CBL with flipped classroom model. We selected malaria as a topic of learning. Malaria remains one of the most important diseases of man in terms of both mortality and morbidity in tropic and subtropic countries. We designed a case of malaria with high fever as the onset symptom based on a real case at the First Affiliated Hospital of Nanjing Medical University. Before class, the students were divided into groups, teachers gave students the key content and a patient’s case, students were asked to analyze the case, engage in self-guided learning, scientific inquiry and collaboration with group fellows, develop critical thinking and problem solving ability, and integrate theory into practice. In class, each group presented the analysis and diagnosis of the case and completed one question assigned by the teacher, and addressed the questions from the teacher and other students at the end of each presentation, which requires active participation of all students. According to the questionnaires submitted by students after class, the motivation to learn was enhanced in flipped classroom combined with CBL model, and their communication skills, abilities of clinical thinking, searching literatures, presenting, cooperative working were improved. Through the multi-direction communication between students and teachers, teachers can better understand the need of students.

During the past teaching process, students came to discuss with us about the final score. They attended classes on time, listened carefully and thought actively. Some students did not come to class, they got high marks by endorsements a few days before the exam. They thought the traditional assessment method is unfair. Therefore, we further adjusted the assessment method. Assessment of students in flipped classroom combined with CBL included diverse approaches: presentation and discussion in class, practical examination of the specimen, multiple-choice questions tested on a computer and written examination. Group presentation was divided into subcategories: the grade assigned by teacher according to the quality of the presentation, ability to distill the most important ideas of the case and the questions group use to motivate class discussion, the grade assigned by the other members of the group; the grade based on classroom participation when other groups were presenting. Results showed no significant difference in average score between two groups. Further analysis showed that no student failed and less students’ score were more than 90 in flipped classroom combined with CBL, the new assessment method improves students' learning enthusiasm and emphasizes the evaluation of their usual grades, more in line with the practical requirements, and narrowed the performance gap between low- and high-performing students in human parasitology course. Therefore, this model could improve overall teaching pattern and help whole development of the students.

On the other hand, flipped classroom combined with CBL is an innovative way to improve teacher’s teaching skill. During all the activities, students may ask a lot of unexpected questions, which are challenges for teachers. Teachers need not only grasp the content of the textbook, but also master the knowledge of the relevant courses and improve communicate skills to help students solve their questions. Moreover, teachers need control the time and content of the discussion in class, and make a summary after each presentation. In addition, our students mainly come from South Asian countries, such as India, Nepal, Pakistan and so on. These countries have been British colonies for a long time in history, and English is the official language of these countries. Foreign students come from these countries generally have good English foundation in reading and writing, but oral English pronunciation has local (regional) accent, some pronunciation is obscure, for example: the pronunciation of the letter "t" is close to the letter "d", the pronunciation of the letter "r" is very close to the letter "l". In the process of communication with international students, teachers should adapt to their unique pronunciation, and overcome communication barriers.

Conclusion

In summary, flipped classroom combined with CBL method is effective and suitable for international students to better learn human parasitology course. 

Take Home Messages

  1. We adjusted the contents and teaching methods to better respect diverse culture backgrounds and accommodate epidemiological differences of international students.
  2. The motivation to learn was enhanced in flipped classroom combined with CBL model. Through the multi-direction communication, teachers can better understand the need of students.
  3. The new assessment method improves students' learning enthusiasm and emphasizes the evaluation of their usual grades, more in line with the practical requirements.
  4. Flipped classroom combined with CBL is an innovative way to improve teacher's teaching skill.

Notes On Contributors

Donghui Zhang, PhD, is the vice dean of School of International Education, Nanjing Medical University, he has a background in laboratory sciences and focus on the medical education of international students. 

Abhinav Kaushik is a medical student studying at School of International Education, Nanjing Medical University. 

Zhipeng Xu is an associated professor working at Department of Pathogen Biology, Nanjing Medical University and teaching human parasitology. 

Min Li is a professor working at Department of Anatomy, Nanjing Medical University and teaching systematic anatomy.

Minjun Ji is a professor working at Department of Pathogen Biology, Nanjing Medical University and teaching human parasitology.

Lin Chen, PhD, is an associated professor working at Nanjing Medical University, She has a background in laboratory sciences and research interests including medical education and public health. ORCiD: https://orcid.org/0000-0002-9876-0168

Acknowledgements

We thank all the MBBS students in Institute of International Education of Nanjing Medical University (grade 2016 and 2017) who participated in this study. 

Figures 1-3 are made by the authors.

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Appendices

None.

Declarations

There are no conflicts of interest.
This has been published under Creative Commons "CC BY-SA 4.0" (https://creativecommons.org/licenses/by-sa/4.0/)

Ethics Statement

As only descriptive data was collected, and no intervention were performed, the study was regarded as exempt from formal ethical approval according to the Medical Faculty of Nanjing Medical University. Special measures were undertaken to guarantee the anonymity of the participants. Verbal consent was obtained from all the students who participated in this work.

External Funding

This work was supported by program “Excellent English-taught Courses for Interna-tional Students of Jiangsu Province” and Educational research project of Nanjing Medical University (2019ZC003 and KCSZ2019004) to Lin Chen.

Reviews

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Barbara Jennings - (23/07/2021) Panel Member Icon
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Thank you to the authors for sharing their work and their findings. I found this article interesting, in their introduction the authors raise points about the globalisation of medical education; iterative curriculum development; and comparisons of didactic and case-based learning methods (CBL).
In the description of their study, the authors describe a comparison of evaluations between consecutive third year undergraduate cohorts. The earlier cohort receiving traditional instruction about parasitology and the latter cohort receiving case-based learning in a flipped lecture format.
However, I think there are some problems that would need to be resolved if the authors revised it for resubmission as a version 2 article, or preferably as a new study.
• Themes are introduced about international cohorts of students and highlighted in the abstract that are not developed subsequently.
• There are some syntax/grammar problems throughout the article that affected my understanding/ clarity.
• The authors acknowledge the issues around anonymity and consent in their ethics statement, but the research governance steps to ensure good practice are not explained in the methods section.
• One of the comparisons at the heart of the study was not valid because different assessment methods were used.
• There are many prior publications about the validity / utility / acceptability of flipped classrooms and CBL in medical curricula, including systematic reviews that could have been cited.
• Perhaps the article could have been presented in a different way – e.g. as a case study of a new parasitology lesson with a flipped classroom design with more detail about the lesson plan and its subsequent evaluation?

Possible Conflict of Interest:

I am an Associate Editor of MedEdPublish. I have posted this review as a member of the review panel and so this review represents a personal, not institutional, opinion.

Simonetta Ausoni - (16/06/2021) Panel Member Icon
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I found it interesting to read this article, which discusses flipped classroom as an educational strategy applied in a course of human parasitology. Here are my comments: 1. As a general comment the text should be revised to eliminate some typos and textual inaccuracies that are present throughout the manuscript. 2. My biggest perplexity regards the value of the study presented. In a human parasitology course, the authors tested only one topic (malaria) for the flipped classroom. It would have been more helpful to see the results of multiple topics, as one student suggested in his/her comment.
Furthermore, the authors state that there were no significant differences in the understanding of the contents and in the ability to self-learning between the study group and the control group. Did the authors have a chance to test whether the flipped classroom experience improved students’ clinical thinking? This is an important issue, but there are no evidences that this was the case.
In conclusion, although the study is interesting, I think that a more articulate approach and detailed analysis would have been useful to reinforce the idea of utility of the flipped classroom strategy.