Flipped Classroom, Problem-Based Basic Surgical Skills Training in Chinese Military Medical University

Rapid changes are taking place in military rescue missions and related concepts and science and technologies around the world. These changes, such as the increase of catastrophic events, the growing number of regional wars, the changes of combat casualty patterns, the needs of medical and health care, etc., make huge challenges and developments in Chinese military medical education.

In the history of medical education in China, “Duck-stuffing” training mode played an important role that made medical students store theoretic knowledge in their minds and pass the written exams. It may be a practicable training method to cultivate a physician, but far from satisfactory among the will-be surgeons, for the lack of surgical skills, especially in military medical university. It is common that many medical graduates, even those with high scores, often do poorly in clinical practice. To revamp the medical educational systems, the Ministry of Health of China has launched new training programs for medical graduates such as standardized residency programs since 2003 and standardized specialists programs since 2010 [1,2]. However, these programs focus only on medical graduates, which is more like a remedy for the current medical education in China.

Therefore, in order to enhance training quality and effect as well as to improve medical undergraduates’ learning abilities, we were launching a new training program in our university [3], which flipped classroom and problem-based learning, two of the world’s most popular training methods, via WeChat Platform was introduced into, thus trying to develop an advanced training method in Chinese military medical university.

Training objects selection

Training methods

Curriculum contents

Evaluation

Table 1: Visual Analogue Scale (VAS) questionnaires.

Statistical analysis

Examination scores and the rate of good

Figure 1: Rate of Level A&B in control group and FC group.

Figure 2: Curriculum Scores of students in control group and FC group.

VAS Scores of students

Figure 3: Result of VAS questionnaires from students.

Table 3: Results of VAS questionnaires from students.

VAS Scores of teachers

Figure 4: Results of VAS questionnaires from teachers.

Table 4: Results of VAS questionnaires from teachers.

Oxford NOTECHS scores of students

Figure 5: Oxford NOTECHS scores of student in control group and FC group.

Basic surgical skills are extremely important for a surgeon, which should be well trained in medical universities, while advanced surgical skills should be trained in residency programs. Unfortunately, the actual main purpose of standardized residency programs in China is to teach medical graduates basic clinical skills, which will result in a waste of hospitals’ resources and residents’ time and cultivate doctors without solid clinical skills. It occurred to be a more and more serious problem under tremendous changes in models of current health care, especially in the military field. Different from surgeons working in hospitals, those who served in combat hospitals or Forward Surgical Teams (FSTs) need to have more solid theoretical foundations and surgical skills because it is more possible for them to face more complicated injuries under extreme conditions.

We first introduced basic surgical skills based on FST to 5^th grade students in military medical university (equals to the last year of the undergraduate program in Chinese medical education model), trying to let our military medical students have good command on basic surgical skills and reach the entry-level of an FST member. To achieve this, we have established several labs, introduced advanced training equipment, designed innovative curriculums [3]. Unfortunately, the training qualities are below expectations under conventional training method, which is to divide the class into three phases including didactic, simulating demonstration and practice. In this training method, students usually don’t have enough chances to practice by themselves for the lack of time which is taken up by a long period of didactic in class, which leads to high scores and low abilities.

Flipped classroom, a new training method designed and kept developing in America since 2007, may hopefully solve the problems of current poor training qualities [4]. It reverses the process of knowledge transference and internalization accordingto the people’s apperception rule, changes the traditional teacher-student relationships and rearranges the use of class period, thus reforming the conventional training method. In flipped classroom, individualized and collaborative learning environment is made for the students with the support of information technology, which could contribute to the formation of a new learning culture and be beneficial to the growth of students [5-7].

In conventional training model, the teacher is typically the central focus of a lesson and the primary disseminator of information during the class period. After class, assignments for students are usually set by teachers for knowledge internalization. Students have to internalize the knowledge after class by themselves, which, however, is less effective. On the contrary, the flipped classroom shifts instruction to a learner-centered model that self-study following the introduction of online videos that teacher have prepared by students before class is the main method for disseminating knowledge, while workshop and group cooperation guided by teachers in class are used for students to apply new knowledge into solving clinical issues and surgical problems, which can achieve the goal of “learning for practice”. Along with the development of mobile information technology and 4G Internet Services in China, WeChat platform becomes more and more popular in students, which provides opportunities not only for more communications but also training method revolution. Through new training method, students’ self-study abilities will be cultivated gradually, which highlights the purpose of learner-centered training model.

It is common that surgical skills training always needs a combination of theories and practices, especially hard practices. We have made demonstrations of surgical procedures and uploaded to the WeChat platform so that the students can preview the videos before class. Several questions about the procedure keys will be raised in the demonstrations, to solve which, students should carry out extracurricular references searching, group discussion and communication with teachers via WeChat platform, all by themselves, thus making a deeper impression. For instance, students will be taught about the harm of severe tension pneumothorax in clinical context and anatomy of intercostal vascular and nerves while watching the demonstration of the surgical procedure of closed thoracic drainage before class, while online collaborative discussions, digital research, and text readings are used to deepen the understanding. In class, students can practice on simulators according to the demo, trying to solve the problems that teachers have raised. In this way, students will understand the key points of the surgical techniques and the reason why they should perform such surgery in that specific way (the cons and pros), thus they can grasp the skills much faster.

Traditional assessment focuses more on accumulation and memory of knowledge and usually evaluates students through unified questions, answers, and standards. Though some students muddle along in normal times, they can get good grades by cramming in last-minute, which leads to “high marks but poor competence”. We reformed the conventional training method into flipped classroom and redesigned the scoring rules which combined surgical skills and theoretical knowledge. In the new scoring system, surgical skills evaluation contains three parts, including daily performance, exam results and teamwork capacity. Problems and shortcomings of the students will be pointed out in time during the evaluation so that their study abilities can be improved while testing. Meanwhile, each group and its teachers will be responsible for their surgical skills training and evaluation independently, which will cultivate team spirit as well as improving students’ humanistic quality. 

Oxford NOTECHS System is to measure teamwork and cognitive skills in the operating theatre, which is widely used in western countries in FST training [8,9]. We first introduced this assessment tool into China to evaluate the individuals’ performance in a surgical team, trying to find whether it was reliable, adaptable and universal in Chinese students. The result showed that students trained by flipped classroom and PBL training method got higher scores in Oxford NOTECHS System. However, limitations appeared that the score of sub-dimension titled “situation awareness” of our students was mostly below standard, which indicated that our students were always focused on what they were doing (e.g. performing surgeries, making decisions, etc.) instead of what they were to do (e.g. evaluating environment, preparing evacuation, etc.). With the development of our training center and scenario simulation lab, we are looking forward to train our students in “real battlefield”.

In our study, the results indicated that the scores of the students in flipped classroom were much higher compared with those in the conventional classroom. Compared with conventional training methods, flipped classroom training method has been recognized not only because it can effectively improve students’ self-learning capacity and arouse their interest in learning, but it can also cultivate their comprehensive qualities such as teamwork spirit.

Although flipped classroom has its distinct advantages, it requires capacities on higher technological and informational literacy for teachers. First of all, teachers need to grasp the necessary technology to shoot, record and clip videos and prepare presentations. Then, they need to know well enough about what they will teach as well as the characteristic and accepting way of each student in the class. 

Last but not least, how to guarantee that students have studied the videos outside of class and how to control the learning pace remains unclear. In our study, nearly 30% of the students in FC group got C or D in exams, which were not satisfied. Further researches on the supervision mechanism after class need to be carried on in the future.

Flipped classroom and PBL training method via WeChat Platform changes the relationship between teachers and students. To ask questions, to discuss, to practice, to raise the solutions, to encourage learning by exams and to promote by assessment with the guidance of teachers along the whole class lead to the improvement of students’ self-learning abilities and an increase of study scores. It can also cultivate the team spirit, which is so important in FST missions. Further researches will be focused on the learning pace control and after-class supervision method to achieve optimal training effects.

Our program was supported by the Major program of Military Logistics Research Project (No. AWS16J031 and No. AWS15J002), and Competitive Curriculum project of the Second Affiliated Hospital of Navy Medical University. We thank Professor Wang Zhinong and Professor Shen Hongliang for their dedication to the whole program.

The authors declare no conflict of interest.

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