Aquifer cases can be used very effectively during classroom flipping exercises. The cases can provide a means of learning the “facts and concepts” in the subject so that students can build the foundational knowledge that they need.

The teaching time with students either individually or in clerkship groups can be used to:

  • see how they can extend those concepts to related cases;
  • investigate areas of uncertainty or controversy; and
  • assess the depth of knowledge and/or reinforce key learning objectives.

By using them in this way, students’ understanding of the case can be assessed, built on, and integrated into patient management.

More about classroom flipping

Contribution by Petra Lewis

Classroom flipping (also known as the backward classroom, or reversed classroom) reverses the traditional roles of in-classroom teaching by an instructor and self-instruction out of the classroom by students. Instead of students learning facts and concepts in class, and then applying them while working through problems or cases at home, the students learn the facts and concepts outside of class–often using technology via recorded PowerPoint™ or whiteboard lectures, online modules or websites, but also through prescribed readings from textbooks or articles.

Classroom time with an instructor is devoted to application, integration, and reinforcement (i.e., the top of Bloom’s Taxonomy, see below). This increases active learning and student engagement, improves understanding, and allows the instructor to both assess and correct knowledge and conceptual gaps with the student in real time as opposed to correcting an assignment.

Classroom flipping has been applied from elementary through post-doctorate programs. For more resources on the web, look for work by Eric Mazur and Salman Khan. The Khan Institute contains over 4,000 videos covering a wide variety of disciplines and educational levels that can be used for classroom flipping.

Key Considerations

  • Pre-learning needs to be appropriate for and focused on the in-class work.
  • Students should be given sufficient notice about classroom flipping activities and assignments (e.g., “The teaching session next Thursday will be based on CLIPP cases 23 and 24, and these must be completed prior to that session”).
  • If pre-work is not done, learners can learn in class, but may not be able to lead a small group session or contribute much.
  • Be careful not to overwhelm learners with the quantity of pre-learning (recommend keeping to under 1 hour).
  • If videos are used, keep them short (< 15 mins.).
  • Consider learner preferences (e.g., watching whiteboard videos versus reading an article). You may need to provide options.
  • Consider a short pretest to assess the level of knowledge retained from the pre-learning activity (using audience response pads works well but is not vital) or incorporate a Q&A session.
  • Use the results of this assessment to define the areas that need to be explained differently or in more depth.
  • Try to structure the activity to a higher level of Bloom’s taxonomy.
  • Make the activity as specific and as personal as possible.
  • Classroom activity can involve individuals, pairs, or groups. You may want to adjust the group size to pre-learning completion and variability of expertise in the group.
  • Use questions based on the upper (4, 5, 6) critical thinking skills defined by Bloom’s Taxonomy ( Use different examples of the same conditions/situations/histories to see how students can apply the knowledge or skills they learned (“far application” of learning).
  • Take the basic concepts learned further; have students apply them to a more complex case.
  • Include feedback about the quality, quantity, and comprehensibility of the pre-learning material.

Some students take time to adapt to a classroom flipping environment, particularly if their prior education has used more passive pedagogies. If the “upfront” work is not done, students may feel uncomfortable or get little out of the active session and may not even attend. A policy that requires attendance may occasionally be needed.

Suggested Classroom Flipping Exercises

Flipping the classroom can be done in a variety of ways.

  • Assign specific cases for students to review before a clinic that is likely to have one or more patients with these disorders (e.g., asthma, COPD). Using appropriate patients as the focus points, see how the student can integrate the key learning points from the case into patient assessment and management. Ask about differences and similarities between the actual cases and the Aquifer cases.
  • Use the Aquifer cases in place of some of the didactic lecture material. Assign students cases containing topics you would normally cover during that didactic session and use the classroom time to go deeper into the topic–to discuss different but related cases or to discuss one or more of the assigned cases in more detail.
  • Use the Aquifer Pediatrics Questions for Further Consideration as a basis for the classroom sessions in pediatrics.
    • Team-based learning “light”: Assign the QFC (higher order Blooms) application questions to teams; assign the same question to all teams
    • Assign similar but different QFCs to different groups. Have the students teach each other at the end.
  • Question pairs: Have one student ask another student a question based on something they learned from the case.
    • Questions should be developed during the pre-work. Students may need encouragement to make sure questions are not too simple.
    • Consider asking students to submit written questions, which you then randomly assign.
    • Can they write a question based on another case they know on this topic?
  • Poll-repoll with ARP (Nearpod, PollEverywhere, clickers): Have students respond to a multiple choice question individually, then allow 2 minutes for discussion of the answer with a partner, then ask them to resubmit their answer. This works especially well with a large group.
  • Structured controversy: Recent changes in preventative health management, imaging, and screening. Debate both sides of the question.
  • Jeopardy: This is a good exercise to consider for the end of the clerkship after students have reviewed a number of cases. Categories may be based on particular cases or topics.
  • Polling type questions: Use questions in the cases that have more than one right answer. Ask students to defend their answers or critique the alternatives. Can be used with groups, pairs, or individuals.
  • Compare and contrast 1: Ask students to compare/contrast certain disease presentations and treatments.
  • Compare and contrast 2: Ask students to compare/contrast the “real world” with the virtual patient and evidence-based medicine. (i.e., Can you think of a time in this rotation that a patient presented/was treated differently than this virtual patient?)
  • Have students write a case-let (mini case) on a given topic.
  • “What if?” applications for the local system: Ask students to work out local systems for common problems (e.g., antibiotic sensitivities, social services, finding medication doses, etc.)

Aquifer Radiology Active Learning Modules

Aquifer Radiology has seventeen workshop modules that can be used in a classroom flipping setting by radiology educators. These assess and extend the key learning objectives from the cases using different images and clinical scenarios.

Aquifer Pediatrics Active Learning Modules

Five learning modules for use in conjunction with Aquifer Pediatrics cases are available for your use. These application exercises, complete with facilitation guides, have been thoughtfully prepared with the aim of minimizing teacher preparation time and maximizing learner achievement. Learn more…

Salman Khan talk at TED 2011

Lage M, Platt G, Treglia M. Inverting the classroom: A gateway to creating an inclusive learning environment, Journal of Economic Education. 2000

Prober CG, Khan S. Medical Education Reimagined: A Call to Action. Academic Medicine,2013; Vol. 88, No. 10.