Flipping the switch: The feasibility of a ???think aloud??? flipped-classroom approach to clinical reasoning instruction


Roy E. Strowd, Charlene E. Gamaldo, Anthony B Kwan, Tiana E. Cruz, Rachel Marie E. Salas

Background: Clinical reasoning is a fundamental skill in medical and allied health professions. Implementation of the evidence-based “think aloud” method (i.e. describing cognitive processes through verbalization) for teaching clinical reasoning has been variable due to time and resource constraints in healthcare education. Materials & Methods: To explore the feasibility of implementing the think aloud method for teaching clinical reasoning, we piloted a flipped-classroom model of instruction to free live-synchronous educational time in a medical school clerkship. Two asynchronous web-based videos were implemented prior to synchronous case-based discussion applying the think aloud method. Performance was assessed by baseline and end-of-clerkship examination and NBME shelf exam; clinical skills by clinical evaluation; satisfaction and student learning styles by survey. Results: The flipped-curriculum was piloted in 38 students; mean age 25+2.2 years; 63% male. Baseline knowledge was low (mean baseline score 43+21%) and improved significantly (mean final score 70+23%; increase 29%, 95%CI 20-37%, p<0.0001) with 91% having higher end-of-clerkship scores. Greater improvement was observed in students who achieved clerkship goals (42% vs 24%, p=0.04) or possessed greater commitment to lifelong learning (39% vs -7%, p=0.02). Conclusion: Flipping the classroom in the neurology clerkship was feasible and provided a time efficient approach to implementing an evidence-based, think aloud approach to clinical reasoning instruction. Given the central role of clinical reasoning in managing the neurological patient and the pedadgoical trends toward standardized patient-instruction and active learning, this model provides an important example for maximizing educational opportunities for medical and allied health trainees.