Over the past 20 years, professors in higher education (particularly those in science, technology, engineering, and medical fields) have seen a gradual exodus away from purely didactic educational experiences to those that embrace more active learning strategies. This emphasis on active learning aims to help our students practice both critical and clinical thinking skills in the classroom, before they leave the structured college environment and move into their experiential rotations.

It is imperative that we give students the opportunity to learn and practice these “thinking” skills before they are released to rotations where they will encounter patients with complex problems. With the large volume of information pharmacy students need to be successful in practice, the Touro College of Pharmacy professors have accepted that it is not possible to present all of this information in their years of study at the college. We are increasing the amount of active learning in the classroom and fostering accountability for students to prepare for class ahead of time. After making this transition last year, I reflected on how I transformed my material from a traditional to a flipped classroom model, and the results I saw from my efforts.

As a clinical pharmacist, I can say with confidence that most pharmacy textbooks are out of date shortly after their publication. Particularly in my field of Human Immunodeficiency Virus (HIV) patient care and management, new data and strategies are published every day. Whatever facts I teach my students in the classroom will likely be outdated by the time they graduate, or at least within 5 years. So the challenge became: how could I cover all the information they need right now, while also showing them lifelong learning strategies that they can use for the rest of their careers? I created a lecture note document in the style of an outline, and supplemented what would have been bullet points in a slide deck with longer explanations, links to clinical guidelines, and graphics. The first page of this document included objectives and pre-class responsibilities clearly listed for the students. At least a week before each class, I posted these modified lecture notes for the students to review. Details of the objectives and activities are listed below.

1. Required reading: For this item I listed the HIV chapter in the pharmacy textbook. Although it is not the most up-to-date source of information, it gives a good overview of the basics and review of the pharmacology of medications used in treating HIV. By making this a required before-class reading, I did not need to cover these basics in the classroom.
2. Pre-class activity: Students were assigned to “fill in” blanks that I had intentionally left in the lecture notes. I made a table of the medications used for HIV, brand/generic names, doses, side effects, selected drug interactions, and clinical pearls. The sections on brand names and dosing were left intentionally blank. Students could easily find this information from a variety of sources, including drug information databases, the required reading in the textbook, or the clinical guidelines I provided as recommended reading. I also left some blanks throughout the lecture notes on concepts that could facilitate discussion rather than rote memorization. For example, I asked students to identify the difference between HIV and AIDS, as well as HIV-related social determinants of health care. Since we discussed these topics during class, students who were unclear on the answer before class could simply take notes during the classroom discussion.
3. Recommended reading: I provided the permanent link to the Department of Health and Human Services HIV Guidelines. This is updated with current information on a periodic basis. Students could use this source to fill in the blanks of their lecture notes very quickly, while also practicing their skills navigating real-world clinical practice guidelines.
4. Pre-class quiz learning objectives: I used these objectives to create a quiz administered in the first 10 minutes of class. These quiz questions were of basic knowledge and recall ability, but rewarded students who completed the pre-class reading and activity homework assignment. Since the course does not include a grade for homework, this was the best way to encourage students to complete their before-class responsibilities.
5. Lecture learning objectives: These are the objectives I hoped the students would achieve by the end of the lecture series. By basing my exam questions on these objectives, students had a clear understanding of what to focus on for the exam without the need for me to verbalize it during our limited class time.

Using this flipped classroom model, students not only practiced their medication information gathering skills, but also collaborated with their peers when conflicting information was found. During class, since the students were already familiar with the basics of the clinical practice guidelines and the medications, I spent only half of the lecture period explaining complicated topics and practice algorithms. For the second half of class, I presented the students case exercises of real patients I have seen in my clinical practice. They were able to answer case questions at a much higher level than I would expect after just a few lecture hours of a difficult topic like HIV. I also noticed the classroom had higher energy and was more engaged than during a typical didactic lecture. Students asked insightful questions, and were able to participate in a spirited impromptu debate about a current clinical controversy in HIV treatment.

When I was a pharmacy student, I was accustomed to a traditional classroom environment. The professors lectured with busy slides, each one filled with important information. The classroom time was spent emphasizing what material would be on the exam with occasional explanations of complex topics. Good students memorized as much information from the slide decks as possible, occasionally read the chapter in the textbook, and did the practice questions (if we were lucky enough to get any). It is not entirely unreasonable that in the first year of my career as a professor I used this same model in my own classroom. This, of course, did not produce satisfied students, nor did the students perform well on my exam questions. I knew I needed to change my model, and I investigated other strategies for effective teaching and learning. I remembered a professor whose teaching style was practical and incorporated lots of active learning techniques. He would post the lecture notes on a Microsoft Word document, with blanks and spaces to fill in extra information. This really opened up more formatting opportunities, since the information for the lecture no longer needed to fit on pre-specified, square slide decks. The notes could flow like a story, or book chapter, with clinical pearls and emphasis sprinkled throughout. Charts and graphs that normally would be cut or split into several slides could exist in their intended size and resolution. During class, I could participate in the discussion rather than trying to write down a transcript of all the things the professor said would be on the exam. I decided to use a modified version of this flipped classroom approach in my next year of teaching.

Despite the seemingly successful pilot in the classroom, I still expected student satisfaction to be low after this new approach. Our student body is understandably averse to change in processes or teaching style, particularly when only one faculty in a team-taught course is using a new approach. I was pleasantly encouraged, however, to review my student evaluations. Several comments from my students are included below.

• “The new style helped me engage in the class other than trying to write down what she says in class.”
• “I really appreciated… the unique handouts for Hep[sic] and HIV. These were very helpful and promoted a more engaging learning experience.”
• “I enjoyed… (the) lecture notes style. It made it so much easier to grasp what could’ve been really difficult topics!”
• “Loved the new style of notes”

Overall, my pilot of this notes style was received well and produced a more active learning environment for my students. Clearly the students preferred this approach to a traditional classroom model. From my perspective as the professor, the time in the classroom was more enjoyable because the students were engaged and excited to learn. Not only did students perform well on my difficult exam questions, but they were satisfied with the process even after the first semester of usage. I believe that student performance and satisfaction improvements are a testament to both the modifications I made to my teaching style as well as utilization of this flipped classroom model. I encourage all higher education faculty to consider reanalyzing the way they deliver material to students, to consider utilization of a flipped classroom model, and to encourage students to take accountability for their own learning. Only through fostering this accountability can we hope to develop our students into excellent practitioners and lifelong learners.